A Good Place Therapy Pacific | Secure Scheduling Form

Secure Scheduling Form (California)

Welcome to A Good Place Therapy Pacific! We are thrilled that you have decided to take the next step in seeking therapy. We look forward to working with you! We are currently accepting new clients for in-person and telehealth sessions.

To schedule your first session with our California practice, please complete this multi-page form. To schedule your first session with our New York practice, complete our New York practice scheduling form.

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 smartphone as photos of your insurance card are required on a subsequent page.

Your First Name *

Your Last Name *

Your Email Address * 🛈

Your Phone Number * 🛈

Please acknowledge that emails and text messages should not contain sensitive information. * 🛈

I understand that emails and text messages are inherently insecure, could possibly be read by third parties, and should not contain sensitive information.

What is your date of birth? * 🛈 +

What is your gender? *

What is your ethnicity?

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? *

What is the name of your employer? 🛈