Do you currently live in Texas? *

Yes

No (Due to laws and regulations, I can only provide services to those who are currently in the state of Texas. Please check therapyden.com, psychologytoday.com, mentalhealthmatch.com for therapists who are licensed in your state. )

Form *

By filling out this form, I understand that I will receive paperwork via the email provided and need to complete it within the next 48 hours to reserve a time slot depending on scheduling availability.

I accept

Important Info *

I have reviewed the following pages: (1) Getting Started (2) FAQs

Yes

Missed Session Fees *

No-call/no-show: $200 Cancellations within 48 hours: $100

I understand I will be charged these fees should I cancel late or no-show.

In-Network Verification *

To verify if I'm in network with your plan, you'll need to call your insurance company's member services number; you can locate this on the back of your insurance card. Group NPI: 1235600834 Personal NPI: 1881215713 New York Medical Behavioral Health Services, P.C. TIN: 832675429 2021 Guadalupe Street Suite 260, Austin, TX 78705

Yes, I am aware and responsible for understanding my coverage (deductible/co-pay).

Legal Name *

First Name

Last Name

Date of Birth *

mm/dd/yyyy

MM

DD

YYYY

Cell Phone *

(###)

###

####

Is this your first time in therapy? *

Yes, I'm excited to start!

No, I recently stopped and looking to transition.

No, it's been a while since my last time.