City Therapy Appointment Request: Individual Therapy

Appointment Request

At this time, we are only providing remote therapy via video or phone.
First Name *
Last Name *
Email*
example@example.com
Phone: *
Scheduling
IndividualCouplesFamily
We are only providing remote sessions via video or phone during the Covid-19 emergency. In order to accommodate your needs and ensure continuation of care once we resume in-person sessions, please indicate your office preference and what your availability will be for those future appointments.
Location*
Availability

OTHER: Please ONLY provide specific hours of availability for a regular weekly appointment
UnavailableAvailable 8 am - 8 pm (for weekly appointment)Other
UnavailableAvailable 8 am - 8 pm (for weekly appointment)Other
UnavailableAvailable 8 am - 8 pm (for weekly appointment)Other
UnavailableAvailable 8 am - 8 pm (for weekly appointment)Other
UnavailableAvailable 8 am - 8 pm (for weekly appointment)Other
UnavailableAvailable 8 am - 8 pm (for weekly appointment)Other
UnavailableAvailable 8 am - 8 pm (for weekly appointment)Other
Additional Scheduling Information
Therapist Request

Please select the therapist(s) with whom you would like an appointment
AnyBenn GrodinShanna King-HarveyAlison NugentCharles SockTakira VictorinJennifer Collins (Remote Only)N/A
AnyMargaret LescherTina HendersonCassandra ReidEric ReidJoyce SilverJennifer KaplanCatherine CusackPamela KirschLeah SyropAnette ErikssonJennifer GraybillLauren SchwartzDenise FredetteNaomi CohnJennifer Collins (Remote Only)N/A
AnyChristine Barillon-IovineLori BeyerDeborah FatoneTamila MisirRia BrownCatherine CusackPamela KirschRachel HarlichNatasha SinghAnnie GoldszmidtKeyanna BlandNachuma (Nickie) RothJennifer Collins (Remote Only)N/A
I would like an appointment with another therapist.I would like to be added to my selected therapist (s) waitlist.If my requested therapist's waitlist is longer than two weeks, I would like an appointment with another therapist .I will inquire at another time.I am open to meeting with any available therapist.
City Therapy Waitlist Policy

For the safety of those seeking treatment, we only hold names on our waitlist for two weeks. If you have not been contacted by us within two weeks, we encourage you to seek services elsewhere. We do not want to delay you from getting help.

If you are in need of services at another time, we invite you to submit a new appointment request.
Are We Right For You
Please tell us briefly why you are seeking treatment*
YesNoOther
YesNoOther
If yes, what medications are you taking?*
YesNoOther
YesNoOther
YesNoOther
Please explain:*
YesNoOther
Please explain;*
How did you hear about us?*
Are you having suicidal thoughts?

If you're thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States.

NATIONAL SUICIDE PREVENTION LIFELINE

1-800-273-8255

LIVE CHAT: click here
Insurance Information
FMNon-binary
Date of Birth*

MonthDayYear
Date
Insurance*
Insurance Member / Subscriber ID # *
Should be Empty:

Appointment Request

Scheduling

We are only providing remote sessions via video or phone during the Covid-19 emergency. In order to accommodate your needs and ensure continuation of care once we resume in-person sessions, please indicate your office preference and what your availability will be for those future appointments.

Availability

Therapist Request

Are We Right For You

Insurance Information