Let's Connect!

Your first step is to simply reach out.

Request Appointment

Office Hours

Monday-Friday 9am-5pm

*** Special requests for appointments needed outside of normal business hours may be considered.

Address

26 Court Street, Suite 1303
Brooklyn Heights, NY 11242

Phone

(917) 476- 9381

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General Contact

First Name

Last Name

Subject

Your Message

Appointment Request Form

An initial 20-minute phone or in-person consultation is available free of charge for individual, couples or group therapy . To schedule an appointment or to obtain additional information about services, please fill out the form below or give me a call.

Appointment Request

First Name

Last Name

Address (if using insurance share the one associated with it)

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Date of Birth

Other

Disclaimer: By filling out this form, you are signing up for important emails from Chamin Ajjan Psychotherapy.

Interested In

Type of therapy seeking:

Individual

Couples

Group

Not sure

Insurance

We are currently In-Network with Aetna insurance. If you are interested in using insurance other than Aetna, you may be eligible for partial reimbursement if you have Out-Of-Network behavioral health benefits. We will check your benefits on your behalf and file all claims.

We offer a sliding scale to those who may have a financial need. Please contact Chamin Ajjan (Phone: 917-476-9381 or Email: chamin@chaminajjan.com) for fee/billing inquiries.

Type of payment:

Private Pay

Aetna

Out-Of-Network Benefits

Other

If using Out-Of-Network Benefits or Other, please specify.

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Personal Identification

Please upload an image of your ID.

A valid government-issued photo identification (ID) includes a driver's license, a state issued. photo ID, or a passport.

Upload Your ID Image Here

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Mental Health History

Have you ever talked with a psychiatrist, psychologist, or other mental health professional? *

Yes

What did you like/dislike about your experience?

Are you being treated by any mental health professional or taking any psychiatric medicine now?

Yes

If yes, please specify

Have you ever been diagnosed with any mental health disorders?

Yes

If yes, please specify

Have you ever been hospitalized for mental health reasons?

Yes

If yes, please specify

Are you currently experiencing any of the following?

Active substance abuse

Self-harm

Suicidal thoughts

Homicidal thoughts

Eating disorder

Court-mandated care

None of the above

Scheduling

Please briefly describe your reason(s) for seeking therapy at this time.

What are you hoping to gain through therapy?

Please specify the days and times of the week you are available for sessions.

Our Therapists

To learn more about our therapists, please visit our website: www.chaminajjan.com/meet-our-therapists/

Please select a therapist who you would like to work with. You may select more than one and our Screen Team will assign you to your best match.

Mollie Aklepi, LMSW

Victoria Licandro, LMSW

Emily Martinez, LMSW

Kelly Puckett, LMSW

Seema Goel, LMSW

Jasmine Rivera-Hackley, LMSW

Lea Kadish, MSWi

No preference

Your Message