A Good Place Therapy & Consulting - Kerrie Thompson Mohr, LCSW & Associates
Secure Scheduling Form
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.
How would you like us to communicate with you? *
Email Risk Acknowledgement & Use Consent *
Do you plan to pay for your sessions at least partially with insurance? *
Did you already provide your insurance information using our insurance card form? *
Secured by Formsite
A GOOD PLACE THERAPY & CONSULTING
225 BROADWAY • SUITE 2010 • NEW YORK, NY 10007 • UNITED STATES
agoodplacetherapy.com/hire-us • (212) 227-4343