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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?
*
Email
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
No
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?
🛈
The Gender & Sexuality Therapy Center
850 7th Avenue, Suite 1106
New York, NY 10019-0029
gstherapycenter.com
(646) 797-4340