Intake Prescreen Form

This form is for requesting outpatient therapy services and is not monitored 24/7. If you are experiencing a mental health emergency, are in crisis, or are having thoughts of harming yourself or others, do not wait for a response. Call 911, the crisis lifeline at 988, or go to the nearest emergency room.

If you need urgent care and are not comfortable being placed on a therapy waitlist, we strongly encourage you to seek immediate support through emergency services.

Please also note: This form is intended to be completed by prospective clients only. If you are a provider referring someone to Ackerman, please share this form directly with your client so we can assess their eligibility.

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The Ackerman Institute for the Family is an outpatient behavioral health provider licensed by the New York State Office of Mental Health as an Article 31 Clinic. Our clinic provides couples & family therapy, offering both in-person and virtual options.  

Our nonprofit clinic provides world-class family therapy services to the public while training the next generation of family therapists. We offer three distinct treatment tracks based on your needs. Each of our treatment tracks provides high-quality mental health care. 

Clinic Therapist

Ackerman therapists are professionals from diverse cultural backgrounds and identities and provide care inclusive of race, gender, ethnicity, sexual orientation, country of origin, and ability. Our team includes student interns, limited permit clinicians, as well as fully licensed clinicians.  

Live Clinical Supervision Program

This live clinical program is a 14-week course of therapy led by a two-therapist team. Behind the scenes, a dedicated group of 4–6 clinicians and a highly experienced, licensed supervisor observe and guide the clinical process. During your sessions, this supervision team offers real-time expert feedback to support your care.

Our clinic operates on an academic calendar, with new therapy cases typically beginning in September or October, and again in January or February.  Sessions are held once per week.

Clinical Fellowship Program

Our couples and family therapists-in-training work under the guidance of expert faculty instructors to provide you with high-quality mental health care.  For trainees, clinic experience is part of the required training and is completed under the supervision of licensed family therapists.

Important Note: Therapy at Ackerman is video recorded for training purposes. These recordings help our therapists provide the best possible care and are an important part of our internationally recognized training program. Videos are viewed only by therapy professionals and are permanently deleted at the end of treatment.

Placement is determined based on clinical and scheduling needs.

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Please note that due to high demand, our clinic often maintains a waitlist. After completing this pre-screening, undergoing insurance verification, and agreeing to the cost of treatment, you may be placed on the waitlist while we work to match you with a therapist. Wait times vary depending on client volume and clinician availability, and we are unfortunately unable to provide a specific timeframe.

The first step in the process is to complete an inquiry form, which helps us determine your eligibility for therapy at our clinic. Whether you are seeking couples or family therapy, we only need one person’s information to get started.

We will ask for your insurance information (if applicable) to help verify coverage and review payment options. We will also collect details about your therapy needs and who will be participating, along with a brief safety questionnaire to identify any potential risks that could affect treatment.

Please note:

• All required fields must be completed. Missing or incomplete information may delay the processing of your registration.
• Your responses are submitted through a HIPAA-compliant, encrypted platform, ensuring your data remains private and secure. Only authorized Ackerman staff will have access to this information, which is used solely to assess eligibility for clinic services.

Once you submit the inquiry form, our team will review your information to confirm eligibility. A team member will then reach out to gather any additional details, secure required consent forms, verify insurance benefits, and schedule an intake appointment.

As a reminder, therapy sessions at Ackerman are video recorded and may include live observation (depending on the program track) to support clinician training and supervision. We appreciate your role in helping us train the next generation of family therapists. While you may opt out of video recording, please note that doing so may significantly extend your wait time.

If yes, please be advised that our intake team may request documentation related to this matter to help determine whether our clinic is the right fit for your needs. If necessary, we may also request a signed release form to communicate with relevant legal or protective services.

Important clinic policy: Please note that our clinic provides clinical therapy only and does not participate in legal proceedings, provide forensic evaluations, or offer testimony and court updates for divorce, custody, or criminal matters.

Please note: For billing purposes, the person in the couple or family whose insurance will be used will be designated as the “identified patient.”

Accepted In-Network Insurance Plans

We are currently in-network with the following commercial and managed care plans:

• Beacon Health Options
• Blue Cross Blue Shield (BCBS) — except plans with Member IDs starting with JLJ, JLH, or BCBS Medicaid
• EmblemHealth / GHI
• Healthfirst
• MetroPlus
• Mental Health Advocates Plan (MHAP)
• New York State Health Insurance Program (NYSHIP)
• Optum / Oxford / UnitedHealthcare (including United Behavioral Health, United Behavioral Health Community Plan, and UMR)
• ValueOptions

Important Notes on Medicaid & Medicare

Medicaid: We accept straight New York Medicaid as well as Medicaid Managed Care plans affiliated with the in-network insurers listed above (with the exception of BCBS Medicaid).

Medicare: We are not in-network with Medicare and are unable to bill a secondary plan if your primary coverage is Medicare.

Out-of-Pocket, Self-Pay & Sliding Scale

If you are uninsured or using an out-of-network plan:

• Standard Rate: Full fee is $400 per therapy session.
• Sliding Scale: We offer sliding scale fees based on household income and family size.
• Accepted Payment Methods: Visa, MasterCard, and American Express.

Please note: It’s important that everyone participating in therapy is aware of the commitment involved and willing to attend. The formal intake appointment—your first billed session—will include all individuals involved in the therapy process.

Thank you for completing our prescreen form.  We look forward to the opportunity to serve you in the near future.