Therapy and LCSW Supervision Intake Request Form for Bluebird Counseling of Western PA
Thank you for your interest in our therapy practice.

Please complete this form to request an intake appointment. Once submitted, a member of our team will contact you within 1–2 business days to confirm scheduling and next steps. 

If requesting services for more than one individual (i.e. yourself and your child) please submit two separate requests. 
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Email *
Full Legal Name  (of prospective client) *
Preferred Name (if different from legal name) 
Date of Birth (of prospective client) *
Name and Number of Persons Responsible (if Client under 18 years old)
Are there any court orders or legal documents related to custody we should be aware of?   *
If yes, please explain:
Phone Number of client  *
Preferred Contact Method
 *
Which state are you currently residing in? 

Please note: Our therapists are licensed to provide services in Pennsylvania and can see clients who are currently located in PA at the time of services. A limited number of our therapists are also licensed in South Carolina or North Carolina.  
 *
What type of appointment are you requesting?

As a reminder, we do not offer medication management at this time.
 *
Required
Did you select that you were interested in family or couples therapy? *
Preferred Appointment Format
 *
Preferred Time of Day
 *
Required
How soon are you hoping to begin therapy?
 *
Briefly describe the concerns you are seeking therapy for.
 *
Is there anything specific you are looking for in a therapist? Or is there any therapist that you were specifically interested in scheduling with? Therapists 
 *
Are you interested in or open to seeing one of our interns? 

As a reminder, our interns do not accept insurance, but rather they are a low cost ($30 per session) cash rate.
 *
Are you currently on any behavioral health medication? *
Required
If yes, who is the prescriber and which one(s)?
How will you be paying for sessions?

As a reminder, we do NOT accept Medicare or Medicaid Primary at this time.
 *
If using commercial insurance, please list your insurance carrier.
How did you hear about our practice?
 *
Is there anything else you’d like us to know before your intake?
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