Appointment Request With a Therapist at Practical Online Therapy

1

State where most virtual sessions will be attended from* This field is required.Our therapists are licensed in NY & NJ only, so they can only see clients virtually in one of those states.

New York

New Jersey

2

Payment Type (Insurance or Private Pay)* This field is required.

Aetna Insurance (In-Network)

Meritain Insurance (In-Network)

First Health (Not Healthfirst) Insurance (In-Network)

Private Pay/ No Insurance/ Out-of-Network

3

Select a Therapist* This field is required.

Any Therapist

Nikia Dennis (T-Th Evenings)

Melanie Joaquin (W-F)

Nixaly Yakubov (M-F, private pay only)

4

Days and times you're available* This field is required.

5

Intake or Consult?* This field is required.

I would like to get started right away: I'd like an intake.

I would like to take my time and interview the therapist first: I'd like a 20 minute video consult.

6

Session Type* This field is required.

Individual

Couples

Family

7

Name* This field is required.Enter the Full Name of the Client

First Name

Last Name

8

Other Adult Participant’s Name* This field is required.Enter the Full Name of the the other adult participant

First Name

Last Name

9

Brief description of your reason for starting therapy at this time* This field is required.

10

Contact Number* This field is required.

Please enter a valid phone number.

11

Email Address* This field is required.

example@example.com

12

Other Adult Participant’s Email Address* This field is required.

example@example.com