C.G. Jung Institute of New York - Low Fee Therapy Application

1
Is your annual household income $55,000 or less?* This field is required.
Yes
No
2
My Products* This field is required.Select Application Fee Below
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Application Fee
Edit
Back
Total cost
3
Name* This field is required.
First Name
Last Name
4
Birth Date* This field is required.
Year
Month
Day
5
Gender* This field is required.Please scroll to see all options which include, Woman, Man, Non-binary, Genderqueer/Non-binary, Prefer to self-describe & Prefer not to disclose
Please Select
Please Select
Woman
Man
Non-binary
Genderqueer/Non-binary
Prefer to self-describe
Prefer not to disclose
6
You selected 'Prefer to self-describe'. How do you describe yourself?
7
Email* This field is required.
example@example.com
8
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Emergency ContactSomeone we can reach if we can't contact you or in an emergency situation.
First Name
Last Name
10
Phone Number* This field is required.
Please enter a valid phone number.
11
Emergency Contact Relationship
12
Highest Level of Education Completed
Please Select
Please Select
High school or less
Some college
College graduate
Graduate degree
Trade/technical training
Prefer not to answer
13
Emergency Contact Phone
Please enter a valid phone number.
14
Occupation trained for
15
Current Job/Employment Status
Please Select
Please Select
Working full-time
Working part-time
Self-employed
Student
Unemployed
Retired
Not currently working
Prefer not to answer
16
Employer (optional)
17
Are you a student?* This field is required.
YESNO
18
School Name* This field is required.
19
Full-time or part-time* This field is required.
Please Select
Please Select
Full-time
Part-time
20
Your average weekly income* This field is required.
21
Partner’s average weekly income
22
Other income sources
23
Resources
24
Number of financial dependents* This field is required.
25
Monthly rent/mortgage* This field is required.
26
Debts/expenses* This field is required.
27
Do you have out-of-network insurance?
YESNO
28
Upload your insurance card* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
29
Upload last 2 years’ tax returns* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
Relationship Status* This field is required.
Please Select
Please Select
Single
In a relationship / partnered
Married
Separated
Divorced
Widowed
It’s complicated / prefer to self-describe
Prefer not to answer
31
You selected 'It’s complicated / prefer to self-describe'. Please describe below.
32
Partner’s age & occupation
33
Number of children
34
Number of children living with you
35
Other household members
36
Family psychiatric history?
YESNO
37
Please share your family's psychiatric history
Huge
Large
Normal
Small
Ok
Ok
38
Reason for seeking analysis* This field is required.
Huge
Large
Normal
Small
Ok
Ok
39
Desired analysis goals* This field is required.
40
Why a Jungian analyst? Optional
Huge
Large
Normal
Small
Ok
Ok
41
Preferred Analyst-In-Training GenderWe ask this to help ensure you feel comfortable and supported in your therapeutic relationship. You may skip this question if you prefer.
Please Select
Please Select
No preference
Woman
Man
Prefer not to say
Prefer to self-describe
42
You selected 'Prefer to self-describe', please describe below.
43
Reason for preference?Optional opportunity to help us understand your choice better.
Huge
Large
Normal
Small
Ok
Ok
44
Availability for sessions
45
How did you hear about us?Select all that apply
Search engine (Google, Bing, etc.)
Psychology Today or other therapist directory
Social media (Facebook, Instagram, etc.)
Insurance provider website/directory
Referral from friend or family member
Referral from another healthcare provider
Referral from current/former client
Community organization or support group
School or workplace referral
Advertisement (online, print, radio)
Website or blog article
Other (please specify)
46
Current illnesses/disabilities
47
Past illnesses/hospitalizations
48
Current medications
49
Last physical exam date
Date
Year
Month
Day
50
Psychiatric history
Huge
Large
Normal
Small
Ok
Ok
51
Substance use (frequency)Please share which substances and the frequency of use for each substance.
52
History of addiction/treatment
YESNO
53
Please share your history of addiction/treatment
Huge
Large
Normal
Small
Ok
Ok
54
12-step participation
YESNO
55
Please share details of 12-step participation
Huge
Large
Normal
Small
Ok
Ok
56
* This field is required.
57
Please confirm all below to proceed* This field is required.
Confirm accuracy
Understand $75 fee
58
SignaturePlease type your name
59
DateDate of signature
Date
Year
Month
Day
60
Please review your information carefully before submitting.

By submitting this application, you acknowledge that:
0a2 All information provided is accurate
0a2 You understand the $75 application fee is non-refundable
0a2 Your information will be kept confidential per HIPAA guidelines
61
Is your annual household income $55,000 or less?* This field is required.
Yes
No
62
Based on the income eligibility requirements of the Affordable Therapy Center, we are unable to accept applications from households with annual incomes above $55,000.
63
Payment Methods
Choose from one of the PayPal options to make your payment.
Should be Empty: