A Good Place Therapy | Secure Scheduling Form

Secure Scheduling Form (New York)

Welcome to A Good Place Therapy! We are thrilled that you have decided to take the next step in seeking therapy. We look forward to working with you! We are currently accepting new clients for in-person and telehealth sessions.

To schedule your first session with our New York practice, please complete this multi-page form. To schedule your first session with our California practice, complete our California practice scheduling form.

Your First Name *

Your Last Name *

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.

What is your date of birth? * +

What is your gender? *

What is your ethnicity?

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

What is the name of your employer? 🛈