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Request For Services
Please complete the form and somebody will contact you within 2 business days
* Indicates required question
First and Last Name
*
Your answer
Email Address
*
Your answer
Phone number
*
Your answer
Preferred Method Of Communication
*
By Phone. I understand a detailed message will be left for me if I do not answer.
By email. I understand that I will need to check my junk/spam folder.
By text. I understand a text will be sent to the phone number provided with information regarding services. I understand intake appointments will NOT be scheduled via text
Method Of Payment
*
Self Pay
Insurance: Highmark, Cigna
Medical Assistance
Out of Network Coverage
I don't know/I am unsure
Other:
Referral Type
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CAC
CYF/Social Services Agency
Medical
Other:
In 2-3 Sentences, please explain why you are seeking therapy at this time
*
Your answer
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