Appointment Request Form

Garden City Therapy

Appointment Request Form

We are currently providing online counseling services only. Please complete the following information and we will reach out to you as soon as possible. Thank you!
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
Name *

First Name Last Name
Select one: *

I am making this appointment for myself I am making this appointment for my child
*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 cannot accept requests from minors. You can call (516) 679-1111 instead for referrals. Thank you.
Information about the person who is making the referral: *
Full Name of Client *
First and Last name of client
Email *
example@example.com (guardian email)
Phone Number *
(Guardian number)
Date of Birth *

Month Day Year
Date of birth of client
Client/Child's Date of Birth *

Month Day Year
Date of birth of client
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reason for Visit (symptoms or current situation or goals) *

0/60
Referred by *
If other please list: *
Select one: *

I will be paying out of pocket ($80 per session) I have BlueCross BlueShield insurance I have Fidelis insurance I have Cigna insurance I have Optum (UnitedHealthcare, Community Health Plan, and Oxford) insurance
ID number: *
Phone number on back of card: *
Enter the phone number that is listed for PROVIDERS or Mental Health
I am currently interested in: *

Individual Therapy Group and Individual Therapy
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 can submit claims on your behalf so that you can obtain out of network reimbursement: First we will check your out of network benefits. Out of network your deductible is typically $1250 each year and once met the cost per visit comes out to about $16 in proportion to our fee (less than the standard In network copay). We help our clients meet their deductible quickly however: Since NYSHIP is out of network for us, after you pay the fee of $80 per visit each time, we submit a claim to insurance. We are permitted to list a reasonable and customary rate of up to $250 per session on the statement which helps you meet your deductible in 5 sessions. Afterwards you continue to pay us $80 per visit (we will then submit the claim of $80) and NYSHIP sends you a check to reimburse you the difference of $64 or more. It is your responsibility to know your benefits and ensure they send you payment and we are not responsible for non-payment by them. Clients find that if they plan on continuing therapy for more than a few sessions it is less costly to see us out of network than to see providers in network.
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.
Select all that would work for you (we may not have your preference at the time of your request but we will try to match it).

Afternoons (M-F) Evenings (M-F) Saturdays (9am to 5pm)
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: *

All appointments are ONLINE (audio/video). 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 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).
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

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