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 *

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 Cobb Psychotherapy LCSW therapists and/or office staff communicating with me by email

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

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? 🛈