Name *

First Name

Last Name

Phone *

(###)

###

####

Preferred method of Contact *

Phone Call

Email

I am interested in: *

Individual Therapy

Group Therapy

Please provide your general availability *

Mondays AM

Mondays PM

Tuesdays AM

Tuesdays pm

Wednesdays AM

Wednesdays pm

Thursdays am

Thursdays pm

Fridays am

fridays pm

Preferred Date

MM

DD

YYYY

I confirm that I currently live in New York State *

Yes

No

I acknowledge all of the following *

Heart Therapy is not a crisis center and cannot respond accordingly. Please call 911 or go to er if you are currently in crisis

Full session fee is $220 per 50 minutes of individual therapy. Superbill will be provided monthly for Out-of-network benefits