This form will be e-mailed to Dr. Brofman. *

I understand that unencrypted e-mail is not a secure form of online communication.

Dr. Brofman will reply via e-mail, unless you indicate a different way to be contacted:

I prefer a response via text (SMS)

I prefer a response via phone

Name *

First Name

Last Name

Phone *

(###)

###

####

For Appointment Inquires: *

I am interested in telehealth appointments (NY State)

I am interested in in-person appointments in Larchmont, NY

I am not inquiring about appointments.

For telehealth appointments, in most cases, you must be physically located in NY State at the time of the appointment. *

I live and/or work in NY state, and would be in NY at the time of an appointment

I would not be in NY for telehealth appointments, but would still like to get in touch regarding a question that I have

I am not inquiring about appointments.

For Appointment Inquiries: Dr. Brofman currently offers daytime hours Mon-Fri (ending by 5pm). *

I understand that Dr. Brofman offers weekday daytime hours for appointments at this time.

I get it! I am not inquiring about appointments.

For Appointment Inquiries: Dr. Brofman is not in-network with any insurance plans. Please visit the Services & Fees tab for info on fees and insurance. Dr. Brofman would also be happy to answer additional questions. Would you like more information about therapy appointments using out of network benefits?

Yes

No