Below we ask a few questions about yourself, and your needs. Please take your time to answer all of the questions as best you can. This helps us to find the right therapist for you.

Once completed, you will be contacted by our admin team with an appointment availability - typically we respond within one business day. Be sure to check your spam folder if you don't see our email. If the time we offer works for you, we'll confirm and schedule the appointment.

If you have questions, email us at admin@nycaffirmative.com

Name*

First Name (name you go by)Last Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

We primarily use email for all communication. Let us know if you are also open to text messages.*

Email OnlyEmail and Text

Date of Birth*

Date

What state do you live in? *

All of our therapists are licensed to see NY State residents (including students). Some can work with NJ residents. Residents of other states can not receive services at our practice.

Our practice is only licensed to work with residents of New York or New Jersey. If you live in another state, you will need to find a therapist who is licensed to practice in your state.

We recommend searching on sites like Zocdoc or Psychology Today, which lets you specificy a region.

Briefly tell us what brings you to therapy at this time. What are you looking for support with?*

You can tell us a bit about yourself, or the specific issues that are coming up for you at this time. This helps us find a therapist that will be a fit for you.

Are you currently experiencing any of the following? ***This form is not a substitute for crisis support. If you are feeling unsafe, or experiencing a psychiatric emergency, please call 988 or visit your local emergency room.****

Thoughts of hurting yourself or someone elseActive substance abuseLegal issues (arrest history, DUI, DCYF involvement, etc.)None of the above

Please describe more about what you selected above.

How are you planning to pay for services?*

I'm paying out of pocketI'm using in-network insuranceI'm using an Employee Assistance Program (EAP)

Please provide additional details about the EAP (reference number, payer, contact info, etc)

Which insurance plan do you have?

Read more about how insurance works here: https://www.nycaffirmativepsychotherapy.com/insurance

What is your insurance member ID Number?

We will attempt to confirm your benefit based on the information provided. If we cannot locate your details we may contact you for your insurance card.

Our full fee is $175. Our sliding scale is for folks who are unable to pay the full fee, and space is limited at each fee level. Please consider your own financial situation, whether you have out of network insurance or other support, and choose the highest fee that you can afford. This helps to keep our services accessible to our community.

I can pay the full fee of $175I can pay the reduced fee of $125I can only afford the lowest fee of $90

If you are using out of network insurance, you will pay up front for sessions and submit your invoices/bills directly to your insurance company. The full fee is $175. Our sliding scale is for folks who are unable to pay the full fee, and space is limited at each fee level. Please consider your own financial situation, whether you have out of network insurance or other support, and choose the highest fee that you can afford. This helps to keep our services accessible to our community.

I can pay the full fee of $175I can pay the reduced fee of $125I can only afford the lowest fee of $90

What days/times are you available for a regular weekly appointment time? Please give us your widest availability so we can best assist you.*

For example: weekday mornings before 11am; weekends any time; MWF 2-5pm

How did you learn about our practice? Knowing this helps us reach more folks in community.*

New Patient Questionnaire

NYC Affirmative Psychotherapy LCSW PLLC