You can always press Enter⏎ to continue
Appointment Request for New Clients with Nixaly at Practical Online Therapy
HIPAA
Compliance
1
Intake or Consult Request with Nixaly Yakubov for New Clients
Nixaly is only accepting Private Pay clients (Out-of-Network Insurance reimbursement, or No insurance), and is available Mondays - Fridays 9am-1:45pm, and some afternoons and late evenings.
Click the Right Arrow below to get started.
Previous
Next
Submit
Press
Enter
2
State where most virtual sessions will be attended from
*
This field is required.
Nixaly is licensed in NY, NJ, & FL only, so she can only see clients virtually in one of those states.
New York
New Jersey
Florida
Previous
Next
Submit
Press
Enter
3
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 Nixaly first: I'd like a 30 minute video consult.
Previous
Next
Submit
Press
Enter
4
Session Type
*
This field is required.
Individual
Couples
Previous
Next
Submit
Press
Enter
5
Book a 45 Minute Individual Intake with Nixaly (Private Pay only)
Previous
Next
Submit
Press
Enter
6
Book a 60 Minute Couples Intake with Nixaly (Private Pay only)
Previous
Next
Submit
Press
Enter
7
Book a 30 Minute Consultation with Nixaly (Private Pay only)
Previous
Next
Submit
Press
Enter
8
Full Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
9
Other Adult Participant's Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
10
Brief description of your reason for starting therapy at this time
*
This field is required.
Previous
Next
Submit
Press
Enter
11
Days and times you're available
*
This field is required.
Previous
Next
Submit
Press
Enter
12
Contact Number
*
This field is required.
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
13
Email Address
*
This field is required.
example@example.com
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
13
See All
Go Back
Submit