NCP Contact

Secure Contact Form

For general inquiries, please complete this form. To schedule your first session, complete our scheduling form.

With your authorization below, we will respond to your general inquiry by email. If you would prefer to not communicate with us by email, you may instead call us at (646) 868-8396, Monday through Friday, 9:00 AM to 5:00 PM ET.

Your First Name *

Your Last Name *

Your Email Address *

YOUR AUTHORIZATION OF THE TRANSMISSION OF YOUR PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS

By signing electronically below, I:

Authorize NYC CBTp therapists and/or office staff to transmit to me, by non-secure email to the address provided above, Protected Health Information (PHI) related to the a) scheduling of therapy sessions and/or other appointments and b) billing and payment for therapy sessions or other services;
Agree that this authorization will terminate only if/when I notify NYC CBTp in writing that this agreement should be terminated;
Agree that I have been informed of the risks, including, but not limited to, the confidentiality of my treatment when transmitting my PHI by non-secure means; and
Understand that I am not required to sign this agreement in order to receive treatment.

Your Signature *

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How may we help you? *

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