What brings you to therapy? What are some things you'd like to work on?
Motivation to Begin
From 1-5, 5 being ready to begin, please select your motivation to begin treatment.
How would you like to meet with your therapist?
*
I am open!
Telehealth Only
Hybrid (Telehealth + In Person)
Upper East Side (In Person)
Upstate NY (In Person)
What is your availability for sessions? Please select all that apply.
*
Are you open to working with a supervised clinician or a provider in training? This will cost less per session than a senior clinician.
Name
*
First Name
Last Name
Age
*
What are your pronouns?
Email
*
Phone
(###)
###
####
How do you prefer us to reach you?
*
Email
Text
Phone
Are you currently in New York State?
*
Yes
No
Are you currently engaging in self harming / injurious behaviors? (cutting, burning etc)
*
-
No
Yes
Practice Fees Note
Please note we are not in-network with insurance, however we are an out of network reimburseable office. Let us know if you want help with this!
LGBTQ+ Match Form Complete!
Thank you for your interest in working with an LGBTQ+ therapist at Aspire Psychotherapy. Our care team will reach out to you within 12 hours to schedule the 15 minute phone call. We look forward to learning more about your goals.
Warmly,
The Aspire Psychotherapy Team
