Appointment Request

Garden City Therapy

Appointment Request
We currently of have a wait list and hope to have availability for appointments in a few weeks. If you would like us to contact you when an opening becomes available please click yes and complete this form. Thank you.*

Yes, contact me when an opening becomes available
Name*

First NameLast Name
Confirm:*

I am making this appointment for myselfThis appointment is for my child (must be ages 12 to 17)
*If this appointment is for your child please put in your own basic contact information first. If they are 18 or older please have them complete and send this form as this option is for parents with minors only.
Age Verification*

Please select here to confirm that you are 18 years of age or older. We only see ADULT clients and cannot accept requests from minors. Please only complete this form for yourself. Thank you.
Information about the person who is making the referral:*
Full Name*
Email*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
Date of Birth - adults only*

MonthDayYear
Date of birth of client
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender on insurance card (required for billing insurance if on file)

FemaleMale
Reason for Visit (symptoms or current situation or goals)*

0/60
Referred by*
If other please list:*
Fees & Insurance:*

I am paying out of pocket ($80 per session)I have BlueCross BlueShieldI have FidelisI have HealthFirstI have CignaI have UMRI have Optum (UnitedHealthcare, Community Health Plan, and Oxford)NYSHIP
ID number:*
Phone number on back of card:*
Enter the phone number that is listed for PROVIDERS or Mental Health
Preference (we will try to accommodate your preference if we have enough availability).*

Weekday MorningsWeekdays 12/1/2pmWeekdays 3/4/5pmEvening
Information about potential counseling with an interning therapist:

Following an intake evaluation ($80), if we think your presenting issues would be suitably addressed by an interning therapist you have the option to work with them at a reduced rate of $50.

If we do not think it would be a suitable match then you have the option to continue at $80 per session with a non-interning clinician.

All interning therapists are in advanced level Masters counseling programs and are under supervision at Garden City Therapy, PLLC
How our practice helps NYSHIP clients out of network

We submit claims on your behalf and have your insurance reimburse us directly. We are able to match your in network copay.
Partnership with Headway for Aetna Insurance

We partnered with a company called Headway which allows us to see clients who have Aetna insurance. Headway will manage your insurance and payment details with you. After an appointment is setup you will receive an email from Headway to verify your email and setup payment for the portion of the fee you would owe.
Registration Link for Headway/Aetna
Does the above arrangement work for you?*

Yes, I will pay $80 per visit and you can submit the claims.No, I will pay $80 per visit but do not want claims submitted.
Check box if interested:

I would like a referral for a psychiatric evaluation and potential medication management. [After your intake we can refer you to a local group psychiatry practice. Their focus is on medication to help treat symptoms while our focus is talk-therapy. The combined approach is often of great help.]
We try and match you with a therapist who you think might be a good fit for you. If you want you can let us know what you prefer when it comes to feeling engaged [i.e. someone who is a bit more lively, someone with a calming demeanor, someone more goal oriented (CBT focus), someone more exploratory (analytic focus), a mixture of these, etc.]
By submitting this form you understand that:*

Garden City Therapy is a private group practice offering routine mental health services and is not a crisis center. If you are experiencing any type of emergency and need immediate assistance, please dial 911. Futhermore, assigned therapists at Garden City Therapy are Licensed Masters Social Workers/Mental Health Counselors and Masters Interning Therapists engaged in ongoing clinical meetings with Director, Michelle Ambalu, LCSW (Ms. Ambalu does not see clients but consults with assigned therapists).
Please confirm acknowledgement that all appointments are ONLINE*

Yes, I understand this is a PHONE/VIDEO appointment
You can expect a response within 24 hours on business days. If you have not heard back in 24 hours please call 516 828 2622 ext.200. Thank you.
www.GardenCityTherapy.com

Hello@TherapyTeam.org
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How our practice helps NYSHIP clients out of network

Partnership with Headway for Aetna Insurance