Room Request

Please use the form below to request rooms for in-person therapy. We will respond to the email address provided.

Therapist Name(Required)

First Last

Therapist Email(Required)

Therapist Division(Required)

You can enter up to 3 patients on this form. How many patients would you like to enter?

One

Two

Three

# 1 Patient Initials(Required)

Current Appointment Day & Time/First Choice of Appointment Day & Time(Required)

In case there isn’t a room available, please give two other options of a day/time that you could meet with this patient(Required)

Additional comments (optional):

# 2 Patient Initials(Required)

Current Appointment Day & Time/First Choice of Appointment Day & Time(Required)

In case there isn’t a room available, please give two other options of a day/time that you could meet with this patient((Required)

Additional comments (optional):

# 3 Patient Initials(Required)

Current Appointment Day & Time/First Choice of Appointment Day & Time(Required)

In case there isn’t a room available, please give two other options of a day/time that you could meet with this patient((Required)

Additional comments (optional):

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.