Contact Form Legal Name * First Name Last Name Chosen Name First Name Last Name Pronouns Date of Birth * MM DD YYYY Email * Phone Number * (###) ### #### Service Requested * Clinical Consultation/Supervision Couples Therapy Family Therapy Gender Affirming Letter Group Therapy Individual Therapy Personality/Psychopathology Assessment Describe in a few sentences why you are reaching out now. * Preferred Method of Payment * Insurance Out-of-network benefits Private pay Requesting sliding scale fee Insurance Plan * Insurance information is used to see if Dr. Lara is an in-network provider for you and to provide a copay estimate. Insurance Member ID * List all of the specific weekdays and times you would be available for ongoing appointments. * Where are you located? * Dr. Lara DiCarlo is licensed to practice in both NY and FL. Where do you prefer to meet? * Virtually (video appointments) In-person only (no openness to meeting virtually) Hybrid (virtual and in-person) If you indicated that you want to meet in-person to any extent, provide the specific days and times that you could meet. Additionally, let me know if you can meet at the times mentioned in Brooklyn, Manhattan, or both. Do you have any questions? How did you hear about this practice? * Thank you! Dr. Lara will typically be in touch within 1 business day. Her practice is closed on the weekends. Check your email (including junk/spam) for her response.
