Please complete this form to request an intake.
Please note before submitting a request:
* We are not able to accept Medicaid or Medicare
* We require a valid credit card to be kept on file for all clients
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Please click to indicate your awareness that we are currently only scheduling clients for online video sessions and that you will need to be physically located in the state of Pennsylvania or Florida for your sessions.
I acknowledge that I will need to be in the state of Pennsylvania or Florida for my online video sessions and understand that in-office sessions are not being offered currently. Online Only *
Preferred Name if Different from Above
Guardian Name: For children under 18, please list name of guardian N/A if not needed
Client Date of Birth
Primary Insurance Type *Please choose your insurance type. The insurances listed are those we are in network with. If your insurance is not listed, we are not in-network with it. ***We are not currently able to accept Medicare or Medicaid/ Medical Assistance, including UPMC for You***
Blue Cross/Blue Shield
UPMC Commercial / Marketplace
Optum / United /UMR
I want to use out of network benefits
I will be paying out of pocket
Primary Insurance ID/ Member Number (write "0000" if not using insurance)
Do you have secondary insurance/ another insurance plan?
Not Using Insurance
What is your secondary insurance?
* Regarding Insurance: If you are using insurance, it is important to understand your portion of the cost-sharing for outpatient therapy for your plan. Are you aware of your copay, coinsurance, and/ or deductible for your plan?
Yes, I know my financial responsibility with my plan.
No, I will need help understanding this.
Not Using Insurance
Please tell us briefly what is bringing you to counseling: Once we have your information, we will reach out to you via email. We look forward to working with you!
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