Request an Appointment Form

Request for an Initial Therapy Appointment

New Patient Inquiry
Name*

First NameLast Name
Phone Number*
E-mail*
Date of Birth*

MonthDayYear
How did you hear about us?*
Where would you like to attend therapy?*

Therapy in officeVirtual therapyHybrid (in office & virtual)
When are you available for an appointment?*

9:00am-12:00pmMondayThursday12:00pm-4:00pmTuesdayFriday4:00pm-9:00pmWednesdaySaturday
Preferred Clinician:*
Health Insurance*
*Insurances NOT Accepted: Medicare, Medicaid, Beacon, NYSHIP, Carelon, Fidelis, Health First, Emblem GHI/HIP.
Please Describe Why You Are Seeking Treatment: *
Disclaimer: Please Allow 48 Hours For A Staff Member To Contact You To Schedule An Appointment.
Should be Empty:

Request for an Initial Therapy Appointment