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

Application Fee* This field is required.There's an application fee of $75. Please note that payment will be collected at the end of the application.

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Low Fee Therapy Application FeeApplication fee for Low Fee Therapy Referral Service.
$75.00Edit
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Name* This field is required.

First Name

Last Name

Birth Date* This field is required.

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

You selected 'Prefer to self-describe'. How do you describe yourself?

Email* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Emergency ContactSomeone we can reach if we can't contact you or in an emergency situation.

First Name

Last Name

Emergency Contact Relationship

Emergency Contact Phone

Please enter a valid phone number.

Highest Level of Education Completed

Occupation trained for

Current Job/Employment Status

Employer (optional)

Are you a student?* This field is required.

YESNO

School Name* This field is required.

Full-time or part-time* This field is required.

Your average weekly income* This field is required.

Partner’s average weekly income

Other income sources

Number of financial dependents* This field is required.

Monthly rent/mortgage* This field is required.

Debts/expenses* This field is required.

Do you have out-of-network insurance?

YESNO

Upload your insurance card* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Upload last 2 years’ tax returns* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Relationship Status* This field is required.

You selected 'It’s complicated / prefer to self-describe'. Please describe below.

Partner’s age & occupation

Number of children

Number of children living with you

Other household members

Family psychiatric history?

YESNO

Please share your family's psychiatric history

Reason for seeking analysis* This field is required.

Desired analysis goals* This field is required.

Why a Jungian analyst? Optional

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.

You selected 'Prefer to self-describe', please describe below.

Reason for preference?Optional opportunity to help us understand your choice better.

Availability for sessions

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)

Current illnesses/disabilities

Past illnesses/hospitalizations

Current medications

Last physical exam date

Date

Psychiatric history

Substance use (frequency)Please share which substances and the frequency of use for each substance.

History of addiction/treatment

YESNO

Please share your history of addiction/treatment

12-step participation

YESNO

Please share details of 12-step participation

* This field is required.

Please confirm all below to proceed* This field is required.

Confirm accuracy

Understand $75 fee

SignaturePlease type your name

DateDate of signature

Date

Please review your information carefully before submitting.

By submitting this application, you acknowledge that:
• All information provided is accurate
• You understand the $75 application fee is non-refundable
• Your information will be kept confidential per HIPAA guidelines

Payment Methods

Choose from one of the PayPal options to make your payment.

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