Contact Embrace Therapy

Name*

First Last

Date of Birth*

Cell Phone

Phone

Email*

Insurance Name

Insurance ID #

Primary Policyholder if different

First Last

Date of Birth of Policyholder, if different

Are you requesting Maternal Mental Health Services?

Yes
No

Your bravery has led you to seek the support you need in this very fragile moment in your life. You are not alone. Let us journey together to grieve through this difficult period and find some solace in the storm.

Please check which maternal health concern you need support with

Antepartum Anxiety/Depression
Postpartum Anxiety/Depression/PTSD/OCD
Miscarriage Loss
Stillbirth/Stillborn Loss

Please check which hospital referred you to Embrace Therapy

New York Presbyterian Hospital
Westchester Medical Center
Crystal Run/Garnet Health Medical Center
Montefiore Medical Center
Jacobi Medical Center
Other, indicate below

Other referring hospital:

Brief description of symptoms, concerns, or thoughts needing therapy?*

We’re back in the office scheduling in-person sessions. Can we meet at one of our offices?

Yes
No

Telehealth is still an option, on a limited basis.

Which location is best for you?

Campbell Hall (Orange County)
Croton-on-Hudson ( Westchester County)
Bronx (Bronx County)

What time is best for you?

Day
Mid-Afternoon
Evening

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855-771-0404

Info@iEmbraceTherapy.com

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