Faculty Referral Service Application

 

To request assistance in obtaining a referral to a PANY Faculty provider, please download the Faculty Referral Service application and follow instructions for submission.

 

PANY Faculty Jennifer Blum, MD, the Faculty Referral Service liaison, will review and contact you with recommendations for a PANY Faculty Referral.  

 

Click on individual links below to downlaod the application: 
Application (.docx - fill out electronically and email or fax)

Application (.pdf - print and fill out by hand, and email or fax)


How to submit your application:

Email or Fax:

PANY abides by HIPAA privacy guidelines, which means that after we receive your application, we will treat it with the utmost care in order to respect your privacy. As an applicant to our Consultation and Treatment Services, you may email your application to our office, with the understanding that email is not a private or secure system. During the COVID-19 pandemic we are unable to accept applications by mail. 

 

  • Email application to This email address is being protected from spambots. You need JavaScript enabled to view it. or fax your application to our confidential, private fax line at 646-754-9540.

 

If you do not receive a phone call or email that we have received your application within 1 week of submission, please contact the PANY office at 646-754-4870.

Thank you.

Psychoanalytic Association of New York
NYU Department of Psychiatry
One Park Avenue, 8th Floor
New York, NY 10016

Telephone: 646-754-4870
Fax: 646-754-9540
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

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