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 (Aetna/Meritain, Anthem Blue Cross Blue Shield, Carelon, Northwell Direct, Optum- Oscar/Oxford/United Healthcare). If I'm in-network with your plan, you are only responsible for your copay after you meet your deductible, if you have a deductible to reach. Many people just have a copay for in-network providers. If you are using out-of-network benefits, this is because I am not in-network with your plan but your plan offers partial reimbursement for our appointments. I will provide you with superbills for you to submit to your insurance company. This is always worth asking your insurance company because some reimburse large percentages. I am happy to guide you with questions to ask them. Private pay means opting out of using insurance completely. Sliding scale fees also require opting out of using insurance completely, which means payments do not go towards any deductibles and you cannot receive reimbursement. 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. Additionally, let me know if you can meet at the times mentioned in Brooklyn, Manhattan, or both. 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.
