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!
Name *

First Name Last Name
Select one: *

I am making this appointment for myself I am making this appointment for someone else
*If this appointment is for someone other than yourself (spouse, child, etc.) please put in your own basic contact information FIRST directly below, and the client's afterwards.
*

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 *
First and Last name of client
Email *
example@example.com (guardian email ok)
Phone Number *
Guardian number ok)
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) *

0/120
Referred by *
If other please list: *
Select one: *

I will be paying out of pocket ($80 per session) I'm interested in reduced cost therapy with an interning therapist I have BCBS insurance I have Fidelis insurance I have Cigna insurance I have UHC/Optum insurance
ID number: *
Please note that we are NOT in-network with NYSHIP plans
Phone number on back of card: *
Enter the phone number that is listed for PROVIDERS or Mental Health
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

Although we are Out of Network for NYSHIP we work with you in the following way: Out of network your deductible is typically $1250 each year and once met the coinsurance (cost per visit) comes out to about $16 in proportion to our fee. 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 email you a monthly clinical statement with all the info needed to provide to your insurance company. 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. You continue to pay us just $80 per visit and NYSHIP sends you a check to reimburse you the difference of $64. It is your responsibility to check your out of network mental health benefits and their responsibility to tell you the details of your plan out of network and to reimburse you accordingly. We can offer guidance on what to ask them. Most clients prefer to stay in therapy anywhere from 4 months to years as they find it helpful and it is great having someone to talk to privately who knows you well. In this case, out of network overtime could be more affordable.
Does the above arrangement work for you? *

Yes, I will pay $80 per visit and would like a monthly statement to be given to me. No, I will pay $80 per visit and do not need a statement to submit to insurance.
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 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 though we typically respond within a few hours. 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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