Appointment Request

Dear Member:

Online appointment requests are available only to current members of our cohort.

To request an appointment, please complete the form below. A member of our staff will contact you to confirm your appointment. Please note that Monitoring appointments are available Mondays and Thursdays only. Treatment appointments availability will depend on the provider you are seeing.

If you are requesting a treatment appointment, please also include your treatment provider in the comment box below.

Please do not use this form to cancel or change an existing appointment. Please call 1-212-562-4572 for cancellations and reschedules.

Required fields are shown in bold.
First Name:    MI:   Last Name: 
     
Address Line 1:
Address Line 2:
City:   State/Province:   Zip/Postal Code: 
   
Email Address:    
Phone:     Alt Phone:   Best time to call:
   
Will this be your first appointment with us?
Preferred day for appointment:
Preferred time for appointment:
Comments:
Note: Appointment requests made through this service are not considered confidential.
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