Name *

First Name

Last Name

Phone *

(###)

###

####

What services are you interested in?

Individual Therapy

Professional Offerings

I understand that this practice can only see clients via telehealth and who are located in Massachusetts or New York at the time of the therapy session. *

Yes

I understand that booking and attending a consultation is an opportunity for Erica and I to get to know each other and see if we may be a good match; this does not guarantee that Erica will be able to take me on as a client or provide other professional services and does not constitute as an immediate therapeutic relationship. *

Yes

I acknowledge and accept the risks of communicating my health information via this form on this web portal and via unencrypted email; I wish to continue despite the risks. *

Yes