Request Your First Session

Name *

First Name

Last Name

Phone *

Country

(###)

###

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Would you like to receive text messages from us?

By selecting "Yes", you consent to receive text messages from Footprint. Message and data rates may apply. You can unsubscribe at any time by texting STOP.

Yes, I would like to receive text messages

No, I do not want to receive text messages

What type of therapy are you looking for?

Individual therapy

Couples/Marriage counseling

Child therapy

Family therapy

Other (please share at the end)

Are you looking for something in person or virtual? *

Please Note: Our in-person office is located in downtown Jersey City near the corner of Newark Ave and Grove St.

Strictly In person

Strictly Virtual

Hybrid (both in person + virtual)

No preference

What days work best for you *

Please select all the apply. Please note: Our weekends are usually unavailable, please be sure to include weekday availability.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

What time of day would work best for you?

Anytime (between 7am-9pm)

Early morning (between 7am-9am)

Late morning (between 9am-12pm)

Early afternoon (between 12pm-3pm)

Late afternoon (between 3pm-5pm)

Evening (between 5pm-9pm)

Are you planning on using insurance? *

Yes

No

What is your Date of Birth? *

MM

DD

YYYY