CTNYC Register Your New Client

Register Your New Client

Clarity Therapy NYC
Your Name*
Your Email*
yourname@claritytherapynyc.com
What is the client’s full name? (If you are registering a client who will be in couples or family sessions, please provide the name of the "identified patient".) *

First NameLast Name
Client Email*
yourname@claritytherapynyc.com
Does your client have a preferred name or nickname? If so, please enter it below.
Is this client a resident of New York State?*

NoYes
Which state does the client reside in?*
Will the client be seeing you from a NY location?*

YesNo
Does this client have Medicare?*

NoYes
Have you opted OUT?*

NoYes
Does this client have Medicaid?*

NoYes
Has the client agreed *not* to use it and/or attempt to claim reimbursement?*

NoYes
Consult took place over:*

PhoneVideo
How will future sessions with this client be conducted?*

In-personTelehealthHybrid (in-person and telehealth)
Have you scheduled a first paid session?*

YesNo
Date of first paid session?*

MonthDayYear
Select a date
Clients preferred pronouns?*
Is this a Testing or a Neuro Psych Eval Client?*

YesNo
Individual/Family/Couples/Groups*

YesNo
Please select the primary CPT code*
What is the fee for the CPT code?*
Enter $ amount
Please select a secondary CPT code, if applicable
What is the fee for the secondary CPT code?
Enter $ amount
Please select the primary testing CPT code.*
What is the fee for the primary testing CPT code?*
add $ amount
Please select the secondary testing CPT code, if applicable.
What is the fee for the secondary testing CPT code, if applicable.
add $ amount
How many testing sessions will this client have? *
What is the date of the second testing session? If it is unknown at this time, please email the billing and admin teams once it is set. *
How often will the client be seen?*

WeeklyTwice WeeklyEvery Other WeekOther
Does the client want to be enrolled in courtesy claims submission? (If yes, a Dx code is required in Simple Practice.)*

YesNoTo be determined/I'm not sure
Does the client want a monthly superbill to submit to their insurance company? (If yes, a Dx code is required in Simple Practice.)*

YesNoTo be determined/I'm not sure
If there is a special billing consideration you would like to discuss, please explain here AND contact Dana directly.
Is the client a minor?*

YesNo
Parent or guardian's name?*

First NameLast Name
Parent or guardian's email address?*
Enter email
Is someone other than the client (partner, parent, etc) paying for therapy? *(Client is NOT a minor, and/or credit card is in another person's name),*

YesNoNot sure
Name of person on credit card/person paying for therapy?*

First NameLast Name
Payer's email address?*
Enter email
Has the client already been sent paperwork via Simple Practice?*

YesNo
Would you like us to send the client any supplemental forms? Check off all that apply.

Release of Information ConsentInformed Consent for Group PsychotherapyCAGE Substance Abuse FormPTSD ChecklistPHQ9GAD-7COVID-19 Informed Consent
Have you worked with this client previously?*

NoYes
Was this client shared with you via our Therapist Matching Questionnaire?*

YesNo
If no, how did this client find you?*

Clarity website or general email inquiryOther Clarity TherapistOnline searchOnline DirectoryFriend or family memberColleague or outside therapistPhysician or psychiatristSocial media
Which Clarity therapist did the client hear about us from?
This may help us manage therapist access of Simple Practice files more quickly. Remember you can grant yourself access to clients by following the steps in the New Consult/Client Checklist.
Please share any additional information or special considerations you would like us to know about this client.
Does this client need a GFE? ( GFE is only required if the client does not have or is not using their insurance)*

YesNoOther
In your opinion, what are the reasons for the consult becoming a client?
Please fill out this form after you have confirmed and scheduled the client's first paid session.

Thank you for your understanding.
Don't hesitate to contact admin@claritytherapynyc.com if you have questions.
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