Full Name Gender Date of Birth MM slash DD slash YYYY Insurance Information (please include Member ID): Billing Address Associated With Insurance Plan: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Plan Subscriber's Name and Date of Birth: Recurring Availability (i.e.: days of week/ times of day available for appointments): Email PhoneBest way to reach you: Reason for VisitAre you looking for Telehealth or in-person visits? Telehealth In Person If no in person appointments are available, would you be open to Telehealth? Yes No If you prefer to be seen in-person, do you wish to come to our Center City Philadelphia or Jenkintown location?JenkintownCenter CityAre you open to all of our therapists or do you have a specific preference? If you have on-hand, please upload pictures of the front and back of your insurance card. Drop files here or Select files Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 300 MB, Max. files: 5. **Please be patient with us while we review the information provided. We will verify your insurance benefits and be in touch about your first appointment within the next three to four business days**