It's a Girl Thing! | SimplePractice

It's a Girl Thing! Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Reason for care

WELCOME TO IT'S A GIRL THING COUNSELING! WE'RE GLAD YOU'RE HERE!

How can we help? (Select all that apply)

Parenting Support Expressive Art Group Therapy Women's Group, Reflections, registration Individual Therapy Family Counseling Mother & Daughter Group Life Skills Group registration Life After High School Group registration Internship or Volunteer Inquiry Clinical Consultation or Supervision Request

What else would you like to share?

For example: what you'd like to focus on, treatment history, your availability, etc.

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Location and Service Preferences

(select all that apply)

In-person Telehealth Either In-person or Telehealth New Paltz Office (243 Main St. #280, New Paltz NY 12561) Maybrook Office (924 Homestead Ave, Maybrook NY 12543) Either Office

What is your availability?

(check all that apply)

Morning Afternoon Evening Weekend First Available

If you are requesting an appointment on behalf of someone else, what is your relationship?

Parent Step-parent Grandparent Relative Other Legal Guardian I have legal authority to seek treatment for this individual N/A. I am seeking services for myself.

Billing & Payment

Payment method

How will you pay for Services?

If you'd like us to verify your insurance coverage please provide the policy holder's name and date of birth (and upload front and back of your insurance card below):

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Insurance card upload

Upload a photo of your insurance card

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.