New Appointment Inquiry Form
Please complete this secure online form in order to request a new patient appointment. Please note that it DOES NOT guarantee that an appointment will be scheduled.  
Sign in to Google to save your progress. Learn more
What is the client's name (child or teen if you are the parent) *
Date of birth for who appointment would be for (if child put child's birthday not parent) *
MM
/
DD
/
YYYY
Phone Number *
Preferred email *

Name of Legal Guardian initiating care for minor patient (if applicable). Type NA if over 18:

 *

If client is under the age of 18, what is the current custody situation?

 *
Acknowledgments 

IMPORTANT: Please note we do not accept UPMC FOR YOU are not in network with any Medicaid (MA, Medical Assistance) or State-funded insurance products at this time. 

Clients enrolled in a state-funded insurance plan will not be able to schedule a new patient appointment!  This includes, but is not limited to: UPMC for You, CCBH, Beacon, Carelon, Gateway, Highmark Wholecare, United Community Plan, Aetna Better Health.  

 *
Required

IMPORTANT: Please note we are unable to accept Children's Health Insurance Plans  (CHIP) This includes, but is not limited to: UPMC for Kids.  

 *
Required

IMPORTANT: We do not offer "co-parenting" services or provide an evaluation or opinion as to parental fitness or child-custody.  

 *
Required

IMPORTANT: We do not provide treatment for alcohol or substance use disorders.  

 *
Required
Therapy Services: Please review our currently available services below and choose which services you're interested in *
Required
Parenting Workshops: Please complete the information below if you would like to be contacted to schedule a Parent Workshop. Please note that these are are an educational service and is private pay only and will not be insurance reimbursable.  Detailed descriptions can be found at https://pittsburghpcit.com/parenting-classes 

Our current availability for therapy services are extremely limited at this time. In the event that we do not have an opening with a clinician in network with your insurance how would you like to proceed:

Please provide a brief description of the reason you are seeking services (anxiety, depression, ADHD, behavioral concerns, trauma  etc.) *
What days and times do you have consistent availability for an appointment? *
Mornings 9:00-11:00
Midday 11-1:00
Early afternoon 1:00-3:00
Late afternoon 3:00-5:00
Evening 5:00-7:00
No Availability
Monday
Tuesday
Wednesday
Thursday
Friday
My preference for appointments: *

Do you have a preferred therapist? (Check all that may apply)

Name of Commercial Insurance Policy: *
Insurance Subscriber Number or Member ID Number. (Type NA if requesting Private Pay Workshop only)  *
Patient Safety

This form is not checked 24/7. If you are having thoughts of suicide or wanting to hurt yourself or someone else, please call your local mental health support hotline, such as 1-888-796-8226 (Resolve for Allegheny County, PA), the National Suicide Prevention Lifeline at 988, 911, or go to your nearest emergency room. 

 *
Required

A member of our administrative team will or call or email you within 2-3 business days. When is the best time for a member of our staff to call and reach you to coordinate scheduling? 

 *

Preferred method of contact:

 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of PittsburghPCIT. Report Abuse
Google Forms