Name *

First Name

Last Name

Phone *

(###)

###

####

Can we text you? *

Yes

No

What kind of therapy are you interested in? *

Couples

Individual

Family

Partner's Name (if applicable)

First Name

Last Name

Location *

I understand Marina is seeing clients remotely via Zoom right now and that works for me.

Please check the following boxes to confirm: *

I understand Marina's fee is $400/session and insurance is not accepted.

I understand Marina is eligible for out of network reimbursement.

Are you located in New York? *

Yes

No