Schedule Appointment

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After you answer the following questions, our intake coordinator will reach out by EMAIL to schedule an appointment.

PLEASE CHECK YOUR EMAILS.

First and Last Legal Name: *

Preferred Name and Pronouns: *

Email Address *

Phone Number *

Address you have listed with your insurance *

Date of Birth *

Insurance Provider (if you will be using insurance)

We do not take Cigna or CHIP.

IBX

Aetna

Optum/United Healthcare

Blue Cross Blue Shield

Highmark

Philadelphia Medicaid Insurance CBH

Allied Trades

Meritain

UMR

Other:

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This form was created inside of Wissahickon Valley Counseling.