Name *

First Name

Last Name

Phone *

(###)

###

####

What type of experience do you prefer

Online

Inperson (West Islip)

Online or inperson

Preferred method of treatment *

Talk Therapy

Creative Arts (Art, Movement, Music, Writing)

Cognitive Therapy

EMDR

I am interested in working with the following therapist virtually

No Preference

Kathy Banks

Ryann Catapano

Diona Ceniza

Lili Chasen

Victor Franco

Petra Gelbart

Katie Halleran

Cassie Kelly

Rachel Kremidas

Danielle LaGrandier

Gracemarie Fong Louis

Kate Lynch

Katelyn McGowan

Dana Moscioni

I am interested in working with the following therapist either virtually or in person

No Preference

Carly Caprioli

Marianne Chasen

Stephanie Keller

Jessie Leete

Katelyn McGowan

Dina Palma

Lindsay Reynolds

Emily Smith

Ania Wasowicz