Contact Form Legal Name * First Name Last Name Chosen Name First Name Last Name Pronouns Date of Birth * MM DD YYYY Email * You will receive an email from me after you submit this form (typically within 1 business day). Check your junk/spam just in case. Phone Number * You may receive a text from my practice after you submit this form with next steps. (###) ### #### Service Requested * Clinical Consultation/Supervision (therapists only- both pre-licensed and licensed) Couples Therapy (private pay/sliding scale fees only) Family Therapy (private pay/sliding scale fees only) Group Therapy (all payment options) Individual Therapy (all payment options) Psychological Testing and Evaluation (some are covered by insurance. reach out directly first with details.) Tell me in a few sentences about what is going on for you and what you may be looking for at this time. * Preferred Method of Payment * I am in-network with many insurance plans, including Aetna/Meritain, Anthem BCBS, Carelon, Northwell Direct, and Optum- Oscar/Oxford/United Healthcare. If you’re in-network, you typically pay only your copay after any deductible. If you are using out-of-network benefits because I am not in-network with your plan, your plan offers partial reimbursement. I provide superbills to submit for reimbursement and can guide you on questions to ask your insurer. Private pay means paying out-of-pocket without using insurance. Sliding scale fees also require opting out of insurance. Payments do not count toward deductibles and cannot be reimbursed. Insurance Out-of-network benefits Private pay Requesting sliding scale fee Insurance Plan * Insurance information is used to see if I am an in-network provider for you and to provide you with a copay estimate. Insurance Member ID * List all of the specific weekdays and times you would be available for ongoing appointments. Please be very specific. * My hours are typically Monday-Friday from 9-5. I do not work on evenings or weekends. Where are you located? List city and state. * Where do you prefer to meet? * Virtually (video appointments) In-person only (meeting primarily in-person) Hybrid (virtual and in-person) If you indicated that you want to meet in-person to any extent, provide the specific days and times that you could meet. My office is in Manhattan (Flatiron). Do you have any questions for me? How did you hear about my practice? * Thank you! Dr. Lara will typically be in touch within 1 business day. Her practice is closed on the weekends. Check your email (including junk/spam) for her response.
