Request an Appointment with Clinical Services

Full Name*

First Last

Pronouns

Gender*

Date of Birth:*

Email*

Phone*

Preferred way for us to reach you (choose 1)*

Do you know what type of service you're requesting? (choose one)*

Person completing this form and relationship to client requesting services for:*

Tell us about the reason you're requesting services:*

Are you looking for Telehealth or in-person visits?*

Some of our services require insurance. If you're seeking Drug and Alcohol Counseling, Mental Health Therapy or LEHB, please provide insurance information, including member ID #.*

Group Number (if available):

Insurance provider:*

If "other", please provide your insurance providers name:

Insurance Plan Subscribers name:*

Insurance Plan Subscribers Date of Birth:*

Client's relationship to the insurance holder (select one):*

Billing Address Associated with Insurance Plan:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Availability (i.e.: days of week/ times of day available for appointments):*

If available, please upload pictures of the front and back of your insurance card

Drop files here or

Max. file size: 50 MB.

Aetna Better Health (CHIP)
Aetna Signature Admin - Trustmark
Alicare
Allied Trades Assistance Program (ATAP)
Amerihealth Administrators
Anthem BC/BS
Carebridge- EAP
Federal BC/BS
Highmark BC/BS
Horizon BC/BS-NJ
Independence Administrators
Independence BC Keystone Health Plan
Independence Keystone Kids (CHIP)
Independence Personal Choice PPO
Law Enforcement Health Benefits
Magellan Behavioral Health- Kidzpartners (CHIP)
Meritain Health
Penn Behavioral Health- EAP
Quest Behavioral Health
TCN- Teamsters Health & Welfare
Medicaid- United Health Care Community Plan
Medicaid Keystone First
Medicaid- Aetna Better Health
Medicaid- Health Partners
Other
None

Aunt
Birth Father
Birth Mother
Brother
Cousin
Daughter
Father
Grandfather
Grandmother
Granddaughter
Grandson
Guardian
Husband
Mother
Nephew
Niece
Other
Self
Sister
Son
Step Brother
Step Father
Step Mother
Step Sister
Step Daughter
Step Son
Uncle
Wife

Request an Appointment with Clinical Services

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