Name *

First Name

Last Name

Phone *

(###)

###

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Preferred Location *

Mamaroneck, NY (Westchester)

Beacon, NY (Hudson Valley)

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

Out-of-Network Acknowledgement *

I acknowledge that IMPACT is an out-of-network provider and does not contract with insurance companies for in-network services. Payment for services is required at the time of your appointment. To assist with reimbursement, we provide detailed receipts (superbills) that you can submit to your insurance company for potential coverage.