Name *

First Name

Last Name

Phone *

(###)

###

####

What type of experience do you prefer

Online

Inperson (West Islip)

Either / No Preference

Preferred method of treatment *

Talk Therapy

Creative Arts (Art, Movement, Music, Writing)

Cognitive Therapy

EMDR

VIRTUALLY ONLINE: I am interested in working with the following therapist(s)

No Preference

Kathy Banks

Carli Caprioli

Jan Casco

Lili Chasen

Samantha Disador

Rhonda Figueroa

Izzuannette Garcia-Cintron

Petra Gelbart

Stephanie Keller

Rachel Kremidas

Danielle LaGrandier

Jessie Leete

Katie Levenson

Gracemarie Fong Louis

Kate Lynch

Katelyn McGowan

Dana Moscioni

Lindsay Reynolds

Kelly Sena

Emily Smith

Ania Wasowicz

Mairéad Wegenaar

IN PERSON: I am interested in working with the following therapist(s) in person

No Preference

Carly Caprioli

Jan Casco

Nicole Connelly

Gaby Espinal-Santiago

Stephanie Keller

Katie Levenson

Katelyn McGowan

Emily Smith

Ania Wasowicz