CP Schedule

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 estimate, complete our insurance card form. You may call us at (718) 260-6042 with any questions.

You may find it easiest to complete this form on your smartphone as photos of your insurance card are required on a subsequent page, if you plan to pay at least partially with insurance.

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.

Would you like to receive updates by email about new services?

Yes, I would like to receive updates by email from Cobb Psychotherapy LCSW about new services being offered to clients

Do you have any form of medical insurance (including Medicaid or Medicare)? * 🛈

Yes

No or I don't know

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) or I don't know

Your Date of Birth * 🛈 +

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? 🛈