Patient Portal

Please use the form below to register or pay for your therapy session with an ICP therapist.

Legal Name (If you use your insurance for sessions at ICP, please provide your legal name)*
First Last
Name (If different from above, please enter your name here. If you are paying for a couples or family session, please enter the second name here.)
First Last
Was your therapy session or intake today?*
- Yes
- No
Session Date*
MM
DD
YYYY

Please enter the date of your therapy session
Please Enter the Name of Your Therapist:*
Is your session a:*
- Therapy session
- Intake session (If you are not using insurance, your intake session is $60)
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*

Your email is required to receive a transaction ID from PayPal.
Session Fee*

Please enter your session fee or copay. If you have no copay, enter 0. This will be checked against ICP records.
Total
$0.00
If you have a copay or session fee, clicking submit will automatically allow you to pay by credit or debit card using Paypal.

Please provide your PayPal transaction ID to your therapist

If you have no copay, clicking submit will complete your registration.

33 W 60th St.
4th Floor
New York, NY 10023

Phone: 212-333-3444
Fax 212-333-5444

Institute for Contemporary Psychotherapy © 2013
Unless otherwise noted, campaigns are copyright of their respective authors.