G&STC 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 (646) 797-4340 with any questions.

If you plan to pay at least partially with out-of-network insurance, you may find it easiest to complete this form on your smartphone as photos of your insurance card will be required on a subsequent page.

Your First Name *

Your Last Name *

What are your pronouns? *

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 The Gender & Sexuality Therapy Center therapists and/or office staff communicating with me by email

Your Phone Number * 🛈

Are you over 18 years of age? *

Yes

Do you plan to pay for your sessions at least partially with out-of-network insurance? *

Yes, I plan to pay at least partially with out-of-network insurance

No, I plan to pay fully out of pocket and/or with an employer benefit

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? 🛈