Appointments - Brooklyn Counseling Services

APPOINTMENTS

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Appointments

Please fill in the form below to schedule an appointment. We will get back to you within 1 business day (Monday if you submit on the weekend).

If you are human, leave this field blank.
Location: *
Bay Ridge
Brooklyn Heights
Dyker Heights
Bensonhurst
East New York
Staten Island
Flatbush
Downtown Brooklyn
Online (e-Counseling)

YOUR DETAILS:
Please fill in your personal and contact details

Full Name: *
Date of Birth
Address
Apt, suite, etc.
Country
City
State
Zip code
Phone *
Email *
Gender (optional)
Female
Male
Are you a new patient? *
YES
NO
Please specify the best time to contact you:
May we leave a messge *
YES
NO

INSURANCE DETAILS:
State N/A if you do not have insurance

Insurance Provider: *
Insurance Plan: *
Insurance Number: *

ARE WE RIGHT FOR YOU:
Are you employed?
YES
NO
Are you on medication?
YES
NO
If yes, what medications are you currently taking?
Do you have any history of drug or alcohol abuse?
YES
NO
Have you been previously hospitalized?
YES
NO
Are you presently suicidal?
YES
NO
Do you think of hurting yourself?
YES
NO

APPOINTMENT PREFERENCE:
Please let us know your preferences for your appointment below.

Appointment Day: *
Please check 'all' days you are available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
or First Available
Appointment time: *
AM
PM
or First Available
Reason for your Appointment? ie. Depression, Family conflict etc
This question is optional and confidential. It will help us connect you with the therapist most suited to your needs.
Please click the button below once to submit your Appointment Request

ARE YOU HAVING SUICIDAL THOUGHTS?

If you’re thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States.

National Suicide Prevention Lifeline

1-800-273-8255

LIVE CHAT: click here

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