CONTACT

If this is an emergency, please dial 988 or go to your nearest emergency room.

Phone: 201-639-4046

E-Mail: info@vicipsychcare.com

YOU CAN ALSO COMPLETE THE FORM BELOW

Please do not include private or confidential information

Name

First Name

Last Name

Preferred Name & Pronouns

Date of Birth

YYYY

What State Are You Located In?

Due to telehealth laws and regulations, you are required to be physically located in a state I am licensed in at the time of your sessions.

Payment Preference

At this time, I only accept insurance through Headway. If you are interested in using your insurance, additional information will be provided to you. Please note I do not accept Medicare or Medicaid.

Insurance Carrier

Please select N/A for private pay and unsure options. If you have a primary and secondary insurance, please list them in order.

Briefly Describe What Is Bringing You Here

Please do not include private/sensitive information as this form is not HIPAA compliant.

Availability

Please let me know the days/times you are available for therapy sessions. * This does not guarantee that I am the appropriate fit or that I will have this time available.

Phone

(###)

###

####

How Can I Get Back To You?

How Did You Hear About Me?