Schedule An Appointment | Guilford Psychological Services

Introduction

Thank you for choosing Guilford Psychological Services. In order to provide the best fit for your therapy needs, we require that you fill out the following form. Please note that in addition to the questions you will be answering, this form also contains important information about our practice (so please read page 2 carefully).

It is important to answer the questions as openly as you can. This should not take you more than 5 minutes. Please note that this form and all of the information you enter is only seen by the clinical coordinator and the Director of GPS.

Frequently Asked Questions

Are you accepting new patients?

Yes. That said, not every one of our team members is currently accepting new patients.

Are you any of your therapists participating providers with any managed care insurance (e.g. Anthem/United/Aetna/Cigna etc)?

In brief, we are not "in-network" with any managed care plans. Look here for more information about this, and how we can help support your using out-of-network benefits: https://guilfordpsychologicalservices.com/faq/

What happens next?

After you complete this form, you will schedule a10-minute phone screen with one of our clinical care coordinators.

Once I have my call with the clinical care coordinator, does this guarantee an appointment with your practice?

Not necessarily. Therapy is highly personal and we pride ourselves in patient-therapist fit. If we do not have the right fit for your needs, we will try to help you find someone who is the right fit!

Thank you for your patience! We look forward to connecting with you!

I understand that Guilford Psychological Services is not in-network with any managed care company and is not in-network with Medicaid or Medicare.

How did you find us?

Internet (google, yahoo, etc.)

My physician or other healthcare provider

A friend, family member, or acquaintance recommended

Psychology Today

Other

Fill in the blank

Client Information

Please complete this section about the person/client being referred.

First Name

Parent Name

Last Name

Age of Client

Client Information Continued

City

Phone Number

Can we leave a message for you at this phone number?

Yes

Can we text you for appointment related information?

By checking this box, I consent to receive messages related scheduling appointments and receiving information about health care benefits from Guilford Psychological Services. You can reply "STOP" at any time to opt out. Message and data rates may apply. Message frequency may vary, text HELP to (203-453-2220) for assistance. For more information, please refer to our privacy policy and SMS Terms and conditions on our website

Do you plan to use any out of network benefits to get some reimbursement for our services, if applicable?

Yes

*We can help you clarify if you have out of network coverage and can submit out of network claims for you if you would prefer-- please see this FAQ for more info.

Client Information Continued

Have you (or your child, if filling this out for them) seen a therapist before? What helped? What didn’t? *

We provide updates a few times a year about new services and providers. We would never distribute your information. Can we put you on our email list?

Yes

Reason for Contact

What services are you interested in? Please check all that apply

Individual Therapy

Couples Therapy

DBT Skills Training Group

DBT Grad Group

Anxiety Group

Intuitive Eating Group

Parenting Support

Family Therapy

Cognitive Behavioral Therapy (CBT)

Exposure and Response Prevention (ERP)

Acceptance and Commitment Therapy (ACT)

Other

Please list

What has been going on? How can we help? *

What are your goals for therapy?

What is your availability like to schedule a session? Please indicate days of the week available (include weekends) and best times to schedule therapy appointments*

Almost Finished!

You are almost done! After you click "SUBMIT," please schedule your intake appointment by clicking on the "Schedule Appointment" link on the next page.

MEET US

Schedule an Initial Call

Introduction

Frequently Asked Questions

Are you accepting new patients?

Are you any of your therapists participating providers with any managed care insurance (e.g. Anthem/United/Aetna/Cigna etc)?

What happens next?

Once I have my call with the clinical care coordinator, does this guarantee an appointment with your practice?

How did you find us?

Client Information

Client Information Continued

Client Information Continued

Reason for Contact

Almost Finished!

You are almost done! After you click "SUBMIT," please schedule your intake appointment by clicking on the "Schedule Appointment" link on the next page.

Location