New Client Interest form

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Please complete the following information, you will be contacted within 48 hours via email.

*Clients must be based in NYS or Florida during scheduled appointments.

Email *

Thank you for your interest!

I am in-network with Aetna, Cigna/Evernorth and United Healthcare UMR for Mount Sinai Employees. I also offer self-pay services. Not in-network with Medicaid/Medicare plans at this time.

Please complete this form and expect instructions to schedule your first appointment!

First/Last Name *

Date of Birth *

YYYY

Do you agree to be contacted via email by this practice? *

Do not agree

Agree

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Can we leave a voice message? *

State of Residence *

Please provide address. *

Phone number *

Please briefly share your presenting concerns: *

Are you interested in Online Counseling? *

Yes

Maybe

What are your pronouns?

Do you identify as Black, indigenous, Hispanic, or person of color?

Yes

Maybe

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Are you covered under any health insurance plans, if so, what plan?

How did you learn about Alexis James Virtual Counseling? *

Send me a copy of my responses.

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