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NYC: Schedule a Session
HIPAA
Compliance
1
Please select the option you would like to begin with:
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I'm experiencing a mental health crisis
I’m looking for a new provider.
I need help with my prescription.
I'm interested in Ketamine Services.
I'm interested in Talk Therapy
I want to schedule a psychiatric consultation
I'm curious about therapy that integrates non-ordinary states of consciousness
I'm not sure yet, I'd like to speak to someone.
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2
Please call 988 for a free, confidential help line. If you are experiencing an emergency, please call 911
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3
What is your name?
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First Name
Last Name
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4
Lead Status
New Lead
Contacted, No Answer/Reply (attempt 1)
Contacted, No Answer/Reply (attempt 2)
Contacted x 3 - no response, Lost Lead
Contacted, Scheduling In Progress
Patient Scheduled! Woohoo!
Contacted, No Answer/Reply (attempt 3)
Other/Pending follow up
Lost Lead - N/A
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5
How did you hear about us?
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Online Search
Another health care provider
Friend/family member
Type option 4
Other
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6
Provider (If Scheduled)
Ben Medrano
Emily Hackenburg
Jessica Colas
Dmitriy Gekhman
Kim Clay
Gali Lodish
Other
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7
Service (If Scheduled)
Medically Supervised Ketamine
KAP
Med Management - no ketamine
Therapy
Other
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8
What phone number and email address can we contact you at?
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Please enter your phone
Please enter your email
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9
Is there anything you want our Scheduling Team to know?
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10
Reason For Lost Lead
Contacted x3 with no response
Cost is an issue
Clinically inappropriate
Spam/Marketing
Too Risky - referred for higher LOC
Other
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