Moses Kushaba Forms

I look forward to meeting with you very soon. Please complete the forms, below, which I have instructed you to complete and email them back to me.

NOTE ABOUT PAYMENT: Your credit card is required prior to the time of your first session. By providing your credit card you agree to the cancellation policy whereby you will be charged for your appointment unless 24-hour notice is given.

Please submit payment here

The following forms are REQUIRED for meeting with Moses Kushaba

Telehealth Consent Form

Adult Intake Form


Child Intake Form

Our psychotherapy fees start at $175 per hour (psychiatry fees start at $200 for 30 minutes).
We do not accept insurance, meaning we are not "in-network" with any health plans.
However, many of our clients submit claims to their out-of-network health insurance and receive 40-60% reimbursement.


We offer a live online Mindfulness-Based Stress Reduction and IFS course for couples.
Thursdays 7-9pm EST from Sept 30th – Nov 11th + optional Office Hours every Monday 12-1pm EST

A HUGE savings compared to couples therapy

Learn More →