Appointment Scheduling Request

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Garden City Therapy, PLLC

Appointment Scheduling

Request Form
We currently of have a wait list and hope to have availability for appointments in a few weeks. Thank you.
Name

First NameLast Name
Confirm:
*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
Information about the person who is making the referral:
Reason for Visit (symptoms of current situation or goals):
Specify briefly if Other OR additional info if needed:

0/60
Full Name
New or Returning Client?
Email
example@example.com
Phone Number
Date of Birth - adults only

MonthDayYear
Date of birth of client
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Administrative Designation if any (required for billing insurance if on file)
Date of Birth

MonthDayYear
Fees & Insurance:
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.
We check insurance benefits before confirming appointments.
ID number:
Phone number on back of card:
Enter the phone number that is listed for PROVIDERS or Mental Health
Do you have another insurance plan for mental health benefits?
We are in network with most plans listed above in the fees & insurance section.

If your primary or secondary insruance carrier was not listed there, we may not be in network, but we can check if you have out of network benefits and offer guidance related to this.

If we are in network with one or both of your inurances, having the full information you provide helps us in checking any benefits you might have depending on the type as well as with billing according to your coordination of benefits.
Insurance Carrier
ID number:
Phone number on back of card:
Enter the phone number that is listed for PROVIDERS or Mental Health
Insurance type:
***Current availability is on Friday and weekends***
Appointment Day Preference (we will try to accommodate your preference if we have enough availability)
Time Preference (we will try to accommodate your preference if we have enough availability).
Therapist Preference (availability per therapist is variable but we will try to offer you a close scheduling time/day match if available)
Referred by
If other please list:
If you would like you can let us know the full name of your family member or significant other so that we can offer you an appointment with a different therapist to avoid conflict of interest (even though we cannot confirm if they are a client here) Thank you
Name of provider and type (i.e. Jane Smith, MD - Primary Care)
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
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?
Check box if interested:
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.]
Please confirm acknowledgement that appointments are ONLINE
By submitting this form you understand that:

Garden City Therapy, PLLC 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 or if temporary support is needed please call Long Island Crisis at 516-227-TALK (8255) 24/7. Furthermore, assigned therapists at Garden City Therapy are Licensed Masters Social Workers/Mental Health Counselors, NYS Permitted Masters Therapists, and Interning Clinicians engaged in ongoing clinical supervision or general review as appropriate to their credential.
You can expect a response within 24 hours on business days (unless wait list in indicated in which case we will contact you when an opening is available). Live answer service is not provided. If you have not heard back in 24 hours please call 516 828 2622 ext.204 and be sure to leave a message. Thank you.
www.GardenCityTherapy.com

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How our practice helps NYSHIP clients out of network

Partnership with Headway for Aetna Insurance