The Compassion Practice | Secure Scheduling Form

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Right to Receive a Good Faith Estimate of Expected Charges

Secure Scheduling Form

Please complete this multi-page form to schedule your first session.

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.

Which days of the week are most convenient for sessions? *

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Sundays

Which times of day are most convenient for sessions? *

7:00 AM to 9:00 AM

9:00 AM to 11:00 AM

11:00 AM to 1:00 PM

1:00 PM to 3:00 PM

3:00 PM to 5:00 PM

5:00 PM to 7:00 PM

7:00 PM to 9:00 PM

Which locations / formats are most convenient for sessions? *

New York Office

Video / internet

Which state will you be physically located in for video / internet sessions? * 🛈

What type of therapy are you seeking? *

Would you like to be matched with a therapist? *

Which therapist would you ideally like to schedule a session with? *

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? * 🛈 +

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

What is the name of your employer? 🛈

THE COMPASSION PRACTICE
447 BROADWAY • FLOOR 2 • NEW YORK, NY 10013

compassionify.com • (347) 391-0086