Please Fill Out The Information To Get Support As Soon As Possible. Thank you!

Full Name *

Child’s Name

Phone *

Address *

City *

Postal code *

Email *

Whom Are You Seeking Therapy For? *

I'm Seeking Services For *

Are you or your child currently on medication?

Yes

No

Are you or your child currently seeing a Therapist/Counselor?

Yes

No

What school does your child attend? (if applicable)

Provide 3 Times You Are Available For Your Complimentary Consultation

What Is the Best Way To Contact You? *

Phone

Email

Text Message

How Would You Like To Receive Services? *

In-Person Only

Telehealth Only

Open to Both

Have you read our out-of-network PRIVATE PAY policy?

Have you read our Private Pay policy? *

Yes

No

How Did You Hear About Us? *

Email and SMS Text Message Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to have Manhattan Teen & Young Adult Psychology therapists and/or office staff communicating with me via email or text message