click here to schedule your free consultation now Contact Form Legal Name * First Name Last Name Chosen Name Pronouns Date of Birth * Email * Phone Number * (###) ### #### Describe in a few sentences why you are reaching out to me now. * Preferred Method of Payment * Insurance Out of-network benefits Private pay Requesting sliding scale fee Insurance Plan * Insurance information is used to see if I am in-network for you and provide a copay estimate. Insurance Member ID * List all of the specific weekdays and times you would be available for ongoing appointments. * Do you have any questions for me? Please make sure you plan to be located in New York State for ongoing appointments before submitting this form. How did you hear about me? * Thank you for reaching out to me. Please check your email for my response. I will typically be in touch within 24 hours. Check your junk mail, too. The email will be coming from drlaradicarlo@gmail.com. Dr. Lara DiCarlo