The Gender & Sexuality Therapy Center | Secure Scheduling Form

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.

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 *

Your Pronouns *

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.

Are you over 18 years of age? *

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

Do you plan to pay for your sessions at least partially with insurance? * 🛈

What is your date of birth? * 🛈 +

Are you currently seeing a mental health provider that is in-network with Healthfirst insurance? * 🛈

Where would your telehealth sessions typically take place? * 🛈

Did you already provide your insurance information using our insurance card form? *

What is the name of your employer? 🛈