Make an appointment Name * First Name Last Name Pronouns Email * Phone * (###) ### #### Are you in NY, NJ or CT? * NY NJ CT Insurance Company Date of Birth Member ID Are you the primary subscriber or a dependent? Primary Dependent Do you have additional insurance? Yes No Would you like to share your availability and scheduling preferences? What are you looking for in a therapist? * How did you hear about us? * Social Media (Instagram, LinkedIn, Facebook, Tiktok) Psychology Today Word of Mouth Kiosk Ad Inclusive Therapists Are you interested in attending one of our Group Workshops? * Yes I'm interested - please send me more information No, not at this time Maybe, I'd like to learn more first Please acknowledge that emails and text messages should not contain sensitive information. I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information. I acknowledge I do not acknowledge Please acknowledge our Privacy & HIPAA Compliance * Liberation-Based Therapy, LCSW PLLC protects your privacy in full compliance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state laws. All personal and health information you share—whether through our website, secure client portal, or in session—is encrypted, stored securely, and never shared without your consent, except as required by law. I acknowledge I do not acknowledge Someone from the office will reach out to you shortly. The office is open M-F, from 9 AM - 5 PM. Except for holidays.For emergencies, please head to your nearest hospital.
