Directions: Please allow approximately 25–30 minutes to complete this form.

Answer each question as best you can. Questions marked with * are required; all others are optional, so feel free to skip anything you’d prefer not to answer.

This person will be contacted only in an emergency, for a safety concern, or if we cannot reach you. This does not give permission to discuss your therapy.

Coordinating with your other healthcare providers is standard, best-practice care, so we ask every client to complete this section. You may also list a family member or other support person involved in your care.

Other provider (if any), e.g., another therapist, couples or family therapist, neurologist, nutritionist or dietitian, or specialist:

Cancellation: Please give at least 24 business hours' notice (Monday through Friday, excluding major holidays) to cancel or reschedule. Otherwise, the full session fee applies, including missed appointments. For example, a Monday 5 PM appointment must be canceled by Friday at 5 PM. This generally applies regardless of the reason; any exception is at the practice's discretion.

Email and other contact: Please bring therapy concerns to your sessions. Scheduling and billing questions are free. Lengthy emails or other non-session work that takes significant clinical time may be billed on a prorated basis, after discussing it with you first.

Recording sessions is standard practice at NYC Cognitive Therapy. It allows your therapist's work to be reviewed in clinical supervision, which helps ensure you receive high-quality care, and it supports accurate documentation. Recordings and transcripts are made with secure, HIPAA-compliant technology, kept confidential, and stay within the practice unless you authorize otherwise or the law requires it. You may withdraw consent in writing at any time, and choosing not to be recorded will not affect your care. If you have any hesitation, we're glad to answer questions before you decide.

I have received and read the Outpatient Services Agreement, including the telehealth information, and the Notice of Privacy Practices, and have had the chance to ask questions. I agree to these policies and consent to treatment, including by telehealth.

 

Your credit card authorization is completed separately in your nTreatment patient portal.

 

 

Welcome to NYC Cognitive Therapy. We provide cognitive behavioral therapy (CBT), an evidence-based approach that is collaborative, active, and focused on the here and now. Your first sessions are an evaluation, and together we'll set goals and a treatment plan. You can ask questions, or request a second opinion, at any time.

Much of the progress in therapy happens between sessions, so your therapist will work with you on practice assignments. You'll never be criticized for finding them hard, but clients who practice tend to improve faster.

Therapy often helps people feel and function better, but no specific outcome can be guaranteed, and discussing difficult topics can be uncomfortable at times. Your therapist may discuss other options, such as medication, which is managed by a psychiatrist or other medical provider.

Sessions are 50 minutes, generally once weekly. Longer or more frequent sessions may be recommended when clinically appropriate, particularly early in treatment. Meeting less than weekly is generally not recommended during active treatment, although sessions may become less frequent as you progress and prepare to finish therapy. Regular appointments help you build momentum, practice new skills, and make steady progress. Sessions are held in person at our office or by video (or by phone if video fails). Your appointment time is reserved for you; please see the 24-business-hour cancellation policy you initialed. If you're late, the session still ends on time. For video sessions, your therapist will wait 15 minutes before logging off.

Call 347-470-8870 and choose your therapist's extension. We aim to return calls within 24 business hours. Clinicians are available by appointment, 8 AM to 9 PM on weekdays and 9 AM to 5 PM on weekends.

We are not a crisis service. If you are in crisis, call or text 988 (Suicide & Crisis Lifeline), text HOME to 741741, call 911, or go to the nearest emergency room. If safety concerns come up during a session, your therapist will work with you to keep you safe, which may include contacting your emergency contact or emergency services.

We are out of network with insurance. Session fees vary by clinician, and your fee will be confirmed with you before your first session. Fees are charged to your card on file after each session, and we’ll give you at least 30 days’ notice of any fee change. Because you’re paying directly, you’re entitled to a Good Faith Estimate of your expected costs. We’ll provide one, or you can request it at any time.

We’ll give you a statement you can submit to your insurer for possible reimbursement; please check your plan’s coverage, deductible, and limits. Scheduling, billing questions, and routine coordination with your other providers are free. Letters, forms, reports, or lengthy emails that take significant clinical time may be billed on a prorated basis, after discussing it with you first. We do not provide court testimony, forensic evaluations, or custody-related services.

You can end therapy at any time, and we encourage you to talk it over in a session first. Your therapist may also suggest ending or a referral if therapy isn't a good fit. With your written permission, we're happy to help with referrals or transfer your records. If we haven’t had a session or contact in 30 days, we’ll consider treatment ended, and you’re welcome to reach out to resume.

What you share is confidential and is released only with your written permission, except when the law requires or allows it, such as:

• Serious risk of harm to yourself or others
• Suspected abuse or neglect of a child or vulnerable adult
• A court order

Within the practice, information is shared only as needed for your care, clinical supervision, scheduling, and billing, and we may contact you with appointment reminders.

Records are kept securely in nTreatment, a HIPAA-compliant electronic health record, and retained as required by New York and federal law. You may request a copy of your records, or ask us to correct them, in writing. If we deny a request, we'll explain why in writing.

Telehealth makes care easier to access, but it has limits: technology can fail, and privacy can't be guaranteed as fully as in person. Please join from a private place, tell your therapist where you are at the start of each session, and keep a phone nearby in case the video drops. Please don't record sessions without your therapist's consent. You may withdraw consent to telehealth at any time.

All clinicians are licensed in New York or are trainees supervised closely by the clinical director, Noah Clyman, LCSW-R, and all follow the ethical standards of their profession. Please tell your therapist if something isn't working. If it can't be resolved, we'll help you find another therapist.

I have received and read the Outpatient Services Agreement, including the privacy and telehealth information, and have had the chance to ask questions. I agree to these policies and consent to treatment, including by telehealth.