A Good Place Therapy & Consulting - Kerrie Thompson Mohr, LCSW & Associates
Secure Insurance Card Form
To request an insurance coverage estimate or to update your insurance information, please complete this form. For general inquiries, complete our contact form. To schedule your first session, complete our scheduling form

As a courtesy, we obtain insurance coverage estimates from insurers. Insurance coverage estimates are subject to change and are not payment guarantees.

With your consent below, we will provide your insurance coverage estimate to you by email. If you would prefer to not communicate with us by email, you may instead call us at (212) 227-4343, Monday through Friday, 9:00 AM to 5:00 PM ET.

You may find it easiest to complete this form on your smart phone as photos of the insurance card are required.
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Email Risk Acknowledgement & Use Consent *
Please refer to your physical insurance card when populating the remaining fields.
To help prevent billing errors, please upload photos of the front and back of the insurance card (two photo files) below.

Are you the insurance plan subscriber? * 🛈
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A GOOD PLACE THERAPY & CONSULTING
225 BROADWAY • SUITE 2010 • NEW YORK, NY 10007 • UNITED STATES
agoodplacetherapy.com/hire-us • (212) 227-4343