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

1
Name* This field is required.
First Name
Last Name
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Birth Date* This field is required.
Year
Month
Day
3
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
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Please Select
Woman
Man
Non-binary
Genderqueer/Non-binary
Prefer to self-describe
Prefer not to disclose
4
You selected 'Prefer to self-describe'. How do you describe yourself?
5
Email* This field is required.
example@example.com
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Aruba
Australia
Austria
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The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
Cape Verde
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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
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Democratic Republic of the Congo
Denmark
Djibouti
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Dominican Republic
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Egypt
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Eritrea
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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
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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
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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Tokelau
Tonga
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Turkey
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Vatican City
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Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Emergency ContactSomeone we can reach if we can't contact you or in an emergency situation.
First Name
Last Name
8
Phone Number* This field is required.
Please enter a valid phone number.
9
Emergency Contact Relationship
10
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
11
Emergency Contact Phone
Please enter a valid phone number.
12
Occupation trained for
13
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
14
Employer (optional)
15
Are you a student?* This field is required.
YESNO
16
School Name* This field is required.
17
Full-time or part-time* This field is required.
Please Select
Please Select
Full-time
Part-time
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Your average weekly income* This field is required.
19
Partner’s average weekly income
20
Other income sources
21
Resources
22
Number of financial dependents* This field is required.
23
Monthly rent/mortgage* This field is required.
24
Debts/expenses* This field is required.
25
Do you have out-of-network insurance?
YESNO
26
Upload your insurance card* This field is required.
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Max. file size: 10.6MB
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27
Upload last 2 years’ tax returns* This field is required.
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Max. file size: 10.6MB
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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
29
You selected 'It’s complicated / prefer to self-describe'. Please describe below.
30
Partner’s age & occupation
31
Number of children
32
Number of children living with you
33
Other household members
34
Family psychiatric history?
YESNO
35
Please share your family's psychiatric history
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Reason for seeking analysis* This field is required.
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Desired analysis goals* This field is required.
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Why a Jungian analyst? Optional
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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
40
You selected 'Prefer to self-describe', please describe below.
41
Reason for preference?Optional opportunity to help us understand your choice better.
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Availability for sessions
43
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)
44
Current illnesses/disabilities
45
Past illnesses/hospitalizations
46
Current medications
47
Last physical exam date
Date
Year
Month
Day
48
Psychiatric history
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49
Substance use (frequency)Please share which substances and the frequency of use for each substance.
50
History of addiction/treatment
YESNO
51
Please share your history of addiction/treatment
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12-step participation
YESNO
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Please share details of 12-step participation
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54
* This field is required.
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Please confirm all below to proceed* This field is required.
Confirm accuracy
Understand $75 fee
56
SignaturePlease type your name
57
DateDate of signature
Date
Year
Month
Day
58
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
59
Is your annual household income $55,000 or less?* This field is required.
Yes
No
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