Name *

First Name

Last Name

Phone *

(###)

###

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Preferred Location *

Mamaroneck, NY (Westchester)

Fishkill, NY (Hudson Valley)

Telehealth preferred (NY, NJ, CT, and FL)

IMPACT is a private pay practice and does not accept or bill insurance. *

I acknowledge that IMPACT is an out-of-network provider and does not bill insurance directly. Full payment is due at the time of service. We can provide a superbill for you to submit to your insurance for possible out-of-network reimbursement.