Get Started

May we leave a message?*

Yes

What is your preferred method of contact for scheduling?*

Phone

Text

Who are you contacting us about?*

Myself

A minor child

An adult dependent

Primary client name
If you are filling this form out for someone else, please include their name here.

What is your relationship to the primary client?

Myself

My Partner

My Child

What kind of therapy are you seeking?*
Please choose all that apply.

Adult Individual Therapy/Counseling

Adolescent Individual Therapy/Counseling

Do you know which counselor you’d like to see?
If the therapist you choose is not accepting new clients, we’ll help you get connected with another provider.

Jennifer Druckman

Logan Druckman

Rose Lupinacci

Unsure, please pick the best fit for me.

Do you have specific scheduling needs?

I have a flexible schedule.

I prefer these appointment times:

Please select as many as possible to help with scheduling:

Weekday Mornings

Weekday Lunches

Weekday Afternoons

Weekday Evenings

What are your payment preferences?*
Please choose all that apply.

I plan to pay privately.

I want to use out-of-network insurance benefits.

I need help with payment options, including how to use my health savings account (HSA).

Is there anything else you'd like us to know at this time?

Location

Hours

Therapy Inquiries

Therapist Services & General Inquiries