Peaceful Way Psychology Therapist Matching Survey

1
What type of Therapy are you looking for?
Individual Therapy
Couples Therapy
Sex Therapy
2
Are you looking for office based sessions or telehealth?We are happy to offer sessions via Telehealth or at our offices at 260 Madison Ave, 8th Floor, New York
Telehealth
Office / In person
Either
3
What times work best for you? Select ALL that apply.
Weekday Mornings (7 am - 12 pm)
Weekday Lunch (12 pm - 2 pm)
Weekday Afternoons (2 pm - 5 pm)
Weekday Evenings (5 pm - 9 pm)
Saturday (9 am - 5 pm)
Sunday (9 am - 5 pm)
4
What issues can we help you with?Kindly note that Peaceful Way Psychology is not a good fit for clients struggling with substance abuse, eating disorders, suicidal ideation, or those with a history of mental health hospitalizations.
Anxiety
Career Counseling
Codependency
Coping Skills
Depression
Divorce
Grief
Infertility
Infidelity
LGBTQIA+ Concerns
Life Coaching
Life Transitions
Marital / Premarital
Men's Issues
Obsessive-Compulsive
Parenting
Peer Relationships
Performance Anxiety
Pregnancy, Prenatal, Postpartum
Phobias
Racial Identity
Relationship Issues
School Issues
Self Esteem
Sex Therapy
Stress
Trauma / PTSD
Women's Issues
5
Do you have a gender preference for your therapist?
Male
Female
Non-Binary
Doesn't Matter
6
Do you prefer your therapist to be a person of color?
Yes
No
Doesn't Matter
7
Do you prefer your therapist to be an immigrant or first generation American?
Yes
No
Doesn't Matter
8
What insurance do you have?
Aetna
Beacon
Blue Cross
Cigna
Oxford
United Healthcare
NOT USING INSURANCE
9
How much can you invest per session? Therapy is an investment in YOU. Sessions at Peaceful Way Psychology range from $95 to $300 per session, depending on the therapist you see and their license level and experience, as well as your insurance coverage. How much can you afford to invest per session for ongoing treatment?
10
How soon would you like to start?
This week
Next week
1-2 wks
2+ weeks
11
What is your full name?* This field is required.
First Name
Last Name
12
What is your email? * This field is required.
example@example.com
13
What is your phone number? * This field is required.
Please enter a valid phone number.
14
Do we have permission to call, text, and email you? (select all that apply)* This field is required.
Email
Text
Call
15
Is there anything else that you would like us to know?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: