Child/Adolescent Appointment Inquiry Form
Full Name of Parent/Guardian Completing this Inquiry
*
First Name
Last Name
Please Identify relationship to the child:
*
Child's Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Parent's Emails for Paperwork and Insurance Questions
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Availability for Session
Monday
Morning (9am-11am)
Early Afternoon: (12pm-2pm)
Afternoon: (3pm-5pm)
Evening: (6pm-8pm)
Tuesday
Mornings (9am-11am)
Early Afternoon: (12pm-2pm)
Afternoon: (3pm-5pm)
Evening (6pm-8pm)
Wednesday
Mornings: (9am-11am)
Early Afternoon (12pm-2pm)
Afternoon: (3pm-5pm)
Evenings (6pm-8pm)
Thursday
Morning: (9am-11am)
Early Afternoon: (12pm-2pm)
Afternoon: (3pm-5pm)
Evening: (6pm-8pm)
Friday
Morning: (9am-11am)
Early Afternoon: (12pm-2pm)
Afternoon: (3pm-5pm)
Evening: (6pm-8pm)
Weekends: (Saturday/Sunday)
Morning (9am-11am)
Early Afternoon (12-2pm)
Therapist Request
*
Please Select
Any Therapist,
Abigale Walker, MHC-Limited Permit
Amanda Dawson, LMHC
Celine Colon, MHC-Limited Permit
David Madden, Advanced Clinical Intern
Jessica Guzman, LMHC
Jonah Mantell, MHC-Limited Permit
Juliette Geilfuss, Advanced Clinical Intern
Kamanie Jialal, Advanced Clinical Intern
Liza Dupler, Advanced Clinical Intern
Matthew Reininger, Advanced Clinical Intern
Michelle Kushmakova, LMHC
Rachel Christensen, MHC-Limited Permit
Taha Ali Alvi, MHC-Limited Permit
If your requested therapist(s) is not available, please tell us your preference
*
I would like an appointment with another therapist
I would like to be added to my selected therapist's waitlist
If my requested therapist's waitlist is longer than two weeks, I would like an appointment with another therapist
Are We a Good Fit?
Please tell us why you are seeking services for your child/adolescent
*
Are you the custodial parent/ legal guardian of the child?
*
Yes
No
Insurance Information
Please select Legal Sex assigned at Birth (This is an insurance requirement)
*
Female
Male
Child's Date of Birth
*
/
Month
/
Day
Year
Date
Primary Insurance
*
Please Select
Aetna
Anthem BCBS
BCBS Healthplus
Cigna
Fidelis
GHI PPO
Healthfirst
MetroPlus
NYSHIP (Out of Network benefits require)
UHC
UHC Community Plan
1199
Self Pay
Insurance ID/Subscriber Number
*
If there is anything else you'd like us to know about you child, please enter the information in the box below:
Submit
Should be Empty: