Contact

First name

Last name

Email

Phone

Birthday

Clinicians you're interested in working with (choose at least 3 if possible. Note that each clinician has their own availability and if we're not able to accommodate in-house, we may connect you with one of our alumni clinicians)

State you reside in / connected to your health plan. Please note if you are NOT in any of the states below, we are unable to provide services for individual or couples work.

New York

Connecticut

Massachusetts

Florida

Front of insurance card

Back of insurance card

Some employers offer EAP benefits (covered therapy). Please list your employer if you'd like us to check if you have this benefit.

What prompted you to seek therapy in this moment?

Services Interested in

Individual Therapy

Couples/Relationship Therapy

Workshops

EMDR-Intensives (90 mins-6 hrs. out of pocket service)

Exclusive Comprehensive/Collaborative Treatment (Includes individual therapy with Clinical Resident & Clinical Director, Full access to groups/workshops, connection to Life Coach service & Digital Materials i.e. Workbooks/Worksheets)

Availability for Sessions (Please note we ask that new clients commit to weekly sessions for at least the first 3 months before decreasing frequency in order to build a strong foundation at the start of treatment)

Is insurance a deal breaker for you? We understand if it is, and we don't want to waste anyone's time.

I can only afford therapy if I am connected with one of your in-network providers. This is a deal breaker.

I can afford to pay out of pocket whether or not my insurance plan offers reimbursement for sessions.

Financing of Sessions. Please let us know what tier you can comfortably pay per session with your clinician.

LATE CANCEL/NO SHOW POLICY

We want to anchor you in clarity about our policies. We have a 48 hour policy as the session time you agree to is saved for you and you alone. We ask for at least 48 hours notice so that should you need to cancel we have the ability to offer your appointment time to another client in need that week. Healing is a community effort and this allows us to continue our work. Should you cancel with less than 48 hours notice, you will be charged the full session fee.

Please note that if you are using a health plan, your insurance WILL NOT help out in covering the session fee so please discuss with your therapist what that late cancel/no show fee is.

Mindful Moments Mental Health Counseling

Begin Your Journey with Us