Last Name (person needing an appointment)
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First Name (Person needing the appoitnment)
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Email Address
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Phone
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Home Address
We need this information to verify your benefits before assigning you to a therapist. If you are planning on paying out of pocket, write "none." This will be kept strictly private.
Date of Birth
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We need this information to verify your benefits before assigning you to a therapist. If you are planning on paying out of pocket, write "none." This will be kept strictly private.
MM
DD
YYYY
Payment Method
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Please tell us how you plan to pay
Effective Date of Insurance
Please enter the date your insurance coverage began.
MM
DD
YYYY
Therapist Preference
While we cannot guarantee a particular therapist, please let us know if you have a certain therapist or gender preference in mind. Please see individual Therapist Biographies for more information about our therapists. If none of your preferred therapists are available, we will assign you based on best match to expertise and your goal for therapy.
Availability
*
Please let us know your availability, so we can try to match you to a therapist who will be able to accommodate you.
*Keep in mind that we currently have a very high demand for evening sessions.
Type of Therapy Requested
Please select the type(s) of therapy you're seeking. Not all of these may be available, but it will help us to choose the best therapist for you.
Please tell us briefly your goals for seeking treatment and your expectations for therapy.
*
This information will be used by our Office to connect you to a therapist that is the best fit.
Have you ever experienced suicidal thoughts or feelings?
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We care about you. If you're thinking about suicide, please do NOT wait for us to contact you with a possible appointment - we may not have availability and we do not have emergency services - Please call 911 or the Lifeline Network is available 24/7 across the United States. Call NATIONAL SUICIDE PREVENTION LIFELINE
1-800-273-8255
If yes to any of the above, please explain.
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Please explain below or write N/A
If yes, please explain and list any diagnosis & treatment.
Please explain.
Are you currently prescribed any medication for a mental health issue?
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Yes
No
If so, Please list all your medications
Are you looking for psychiatric medication?
Please keep in mind that we do NOT provide psychiatric medication at Brooklyn Psychotherapy. We suggest you visit our RESOURCES tab above.
Are you currently dependent on or using an non-prescribed recreational substance?
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(such as opiates, barbiturates, methamphetamines, etc)
We are not a substance abuse provider, and we recommend that you seek treatment first for any substance abuse issues before seeking psychotherapy.
Please tell us more.
*
If you are taking an addictive substance, please tell us what it is an how often you are using.
We believe in a harm reduction model, however, substances like fentanyl and xylazine are currently found in many drugs in nyc, making drug use potentially life threatening at any time. We would
encourage you to stabilize any dependency issues before beginning psychotherapy. NYC has resources and information at https://www.nyc.gov/site/doh/health/health-topics/alcohol-and-drug-use-services.page or you can call 988 24/7 for assistance and resources.
Name of referral source
If you were referred by a provider, please let us know their name so we can we can thank them! If you were referred by a friend, we need to make sure you're assigned to a different therapist.
Is this a repeated appointment request?
Have you reached out to us before?
Returning Client
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Are you a returning client?
If yes, do you want to return to the same therapist or be assigned to someone new?
Thank you for taking this important first step towards starting therapy. Unfortunately, we may not currently have any available appointments due to the great volume of requests that we are receiving. ONLY if an appropriate appointment time becomes available. If you do not hear back from us offering you an appointment, please feel free to check back in a few weeks via email to office@brooklynpsychotherapy.org or by sending a new appointment request. If you are having an emergency or feeling suicidal, please call 911 or visit a hospital right away.
If you are in need of an immediate appointment, please see the list of resources for places that may have appointments more readily available. (Please note we are not affiliated with any of these listings).
Child Therapy, Couples therapy, or Medication Management , we are excited that Williamsburg Therapy Group will provide clients referred by us - or this site - with those services with discounted rates. Please click here for more information.
