Name *

First Name

Last Name

Phone *

(###)

###

####

Do you live in the State of New York? *

Yes

No

How did you hear about Heart Matters? *

Google Search

Social Media

Referral

Other

We only accept Cigna insurance working with select clinicians; however, we do provide super bills to our out of network patients. If you would like to make use of your insurance coverage, please confirm insurance provider *

Cigna

I am a private paying patient

Other

What services are you interested in? Check all that apply

Individual Therapy

Couples Therapy

Family Therapy (to include minors)

Growth Groups Workshop/Webinar

If you are a Christian, how important is your faith to you in your day to day life?

Very Important

Mildly Important

Not Important

Are you open to working with our Therapy Interns (under excellent supervision), who also provide a lower fee option? *

Yes

No

Indifferent