Counseling Referral Select Therapy Group or Individual You Want a Call Back from:* South Shore Counseling-Amityville 217 Merrick Road Suites 212 and 211B Amityville 11701South Shore Counseling-Woodbury 20 Crossways Park North Suite 400 Woodbury 11797South Shore Counseling- Wantagh 3305 Jerusalem AvenueSuite 207 Wantagh 11793Metro Psychotherapy & Counseling 4080 Hempstead Turnpike, Bethpage, New York, 11714Lock & Key Therapy 20 Hicksville Road, Suite 5 Massapequa, NY 11758Journey Counseling Babylon Village, NY 11702 and Lindenhurst Village, NY 11757Balance Counseling 755 New York Ave, Suite 230 Huntington, NY 11743Neuropsychological Institute Long Island 98 Park Avenue, Babylon, NY 11702Kenneth Corbin LCSW-R 188 D Park Ave Suite 3 Amityville NY,11701 South Shore Counseling* example@example.com Metro Therapy* example@example.com Ken Corbin* example@example.com Neuropsychological Institute* example@example.com Journey MHC* example@example.com Lock and Key* example@example.com Patient Name* First NameLast Name Patient Date of Birth* /Month /DayYear Patient Email* Patient Mobile Phone Number for Texting (SMS)* Please enter a valid phone number. Does the patient prefer in-person or virtual sessions?* Please Select Virtual Visits In-Person Prefer Option for Both Payment to be used for Therapy* InsurancePrivate Pay Insurance Name and Policy #:* Do You Have Availability for a Commitment to:* Weekly SessionsBiweekly SessionsMonthly Sessions Reason you want Counseling?* Send My Referral Should be Empty:
