Name *

First Name

Last Name

Is the client a child? *

Yes

No

Phone *

(###)

###

####

Would you like to receive text messages from us? *

By selecting "Yes", you consent to receive text messages from CHR. Message and data rates may apply. You can unsubscribe at any time by texting STOP.

Yes

No

Type of therapy* *

Individual Therapy

Couples Counceling

Child Therapy

Other (please specify)

Are you looking for something in-person or virtual? *

Our in-person office is located in downtown Jersey City. Please select all that applies.

In-Person

Virtual

Hybrid

What days work best for you? *

Please select all the apply.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What times work best for you? *

Please select all that apply.

Anytime (7AM–9PM)

7AM–9AM

9AM–12PM

12PM–3PM

3PM–5PM

5PM–9PM

Will you be using insurance? *

Yes

No

Your Date of Birth *

MM

DD

YYYY

Do you wish to meet with a specific therapist?

Please select the therapist(s) you wish to meet with.

Not sure. I would be open to recommendations.

Milli Shah Bhashyam

Sandra Catinello

Kayla O’Connor

Eliza Gloragille

Taylor Eutsey

Molly Farrell

Tara Frederick

Sally Jang

Cleve Graver

Cathy Hong

Maggie McElwain

Gracie Jerschina

Kyra Makowsky

Diante Jordan

Geraldine Lopez

Grace McAlindin

Jackie Uveges

Gabriella Nelson

Uma Patel

Elba L. Perez

Katie Solman

Priscilla Schmitt

Hunter Tarvin

Ghalia Zelfo

Amanda Swatko

Asmaa Ahmed