AGP Schedule

Secure Scheduling Form

Welcome! Our offices are temporarily closed due to COVID-19. However, we are accepting new clients and serving all clients via our secure telehealth platform.

To schedule your first session, please complete this multi-page form. For general inquiries, complete our general contact form. To request a benefits quote, complete our insurance card form. You may call us at (212) 227-4343 with any questions.

if you plan to pay at least partially with insurance and haven't already provided insurance information, you may find it easiest to complete this form on your smart phone as photos of your insurance card are required on a subsequent page.

Your First Name *

Your Last Name *

How would you like us to communicate with you? *

Phone

Your Email Address *

Email Risk Acknowledgement & Use Consent *

I understand that the use of email is inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to A Good Place Therapy therapists and/or office staff communicating with me by email

Your Phone Number * 🛈

Do you plan to pay for your sessions at least partially with insurance? *

Yes, I plan to pay at least partially with insurance

No, I plan to pay fully out of pocket and/or with an employer benefit (e.g. Lyra Health)

Did you already provide your insurance information using our insurance card form? *

Yes, I already provided my insurance information

No, I did not already provide my insurance information

What is the name of your employer? 🛈