New Client Admission

New Client Admission

Welcome to TalkNY! Please complete the form below to get started with TalkNY's mental health support.
After completing this admission form, we will verify your insurance and will then email you to get started with a therapist from our team. If you do not hear from us within 48 hours, please reach out to Taylor at booking@talknytherapy.com.

If your situation is an emergency, please contact 911 or go to the nearest emergency room.

***You must be physically located within New York to receive services from TalkNY
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Current Date*

MonthDayYear
Date
Chronological Age
Age
Name of Insurance*
Member ID*
Please upload the FRONT and BACK of your insurance card.*

Cancelof
Please upload a copy of your Driver's License or another valid form of ID.*

Cancelof
If you prefer to hold therapy sessions in a language other than English, please specify:
How did you hear about us?*
Please Specify*
In brief, what is the main reason you are seeking support? I.e. Anxiety, PTSD *
Are there any specific therapy modalities you are interested in?

CBTDBTEMDRIFSI do not have a preference at this timeOther
How did you hear about us?
Please list which therapist profile you came across on Psychology Today or Welltrack Connect*
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