Book a Boss Mom Consult

First name*

Last name*

Email*

Phone*

Preferred contact method

Are you a new or existing client?

New

Existing

What brings you in right now?

Stress/Burnout

Anxiety

Depression/mood concerns

ADHD/executive functioning

Parenting support

Relationship/family concerns

Work/life balance

Other (please describe)

Briefly describe what you want support with

Preferred appointment timing

Weekday mornings

Weekday afternoons

Weekday evenings

Weekends (limited/if available)

Flexible

Are you seeking therapy, consultation/coaching-style support, or unsure?

Are you using insurance or self-pay?*

If using insurance: carrier name

Any preferences we should consider when matching you (provider preference, modality, etc.)

I understand this request is not a crisis service. If I am in danger or need immediate help, I will call 911 or go to the nearest ER.

(516) 847-5192

Clients may call, text, or email us at any time. Our team will respond within one business day to all inquiries.

Valley Stream, NY 11581

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