Name *

First Name

Last Name

Phone *

(###)

###

####

I am interested in: *

Therapy

Coaching

Have you been to therapy or had a coach before? *

Yes

No

Please let me know how you found my practice: *

Manhattan Alternative

Psychedelic.Support

TripSitters.org

Third Wave Directory

Psychology Today

Brooklyn Psychedelic Society

Referral

Other

Acknowledgement of out-of-network practice. *

I acknowledge that Vibe and Thrive Psychotherapy & Coaching is an out-of-network provider and does not take insurance. If I would like to receive out-of-network benefits I will need to confirm with my insurance. Superbills are provided upon request. Superbills are only available for therapy.