Information Request
Thank you for your interest in South Shore Counseling! Please complete this form, and one of our Administrative Staff members will contact you as soon as possible. If you prefer, please call (516-785-0323), or send us an email (info@sscpsli.com).
Name
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First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How would you like us to contact you?
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Please Select
Phone
Email
Are you seeking therapy for yourself or someone else, and if so, who?
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Are you looking to begin in-person or virtual sessions?
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Please Select
In-Person
Virtual
Prefer option for both
If you're looking for in-person sessions, which location(s) are you looking to meet?
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Please Select
Wantagh
Woodbury
Amityville
No Preference
N/A
If you plan on using insurance, which insurance company and plan do you have? If you are paying out-of-pocket, please enter that here.
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Please list your availability for weekly sessions (days/times). We cannot guarantee the exact times you list, but we will try our best.
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Please feel free to list any information you would like us to know below; also, feel free to list which therapist(s) you would prefer to meet with. We cannot guarantee availability for a particular therapist, but we will try our best to place you. Enter N/A if there is none.
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Submit
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