Full NameGenderDate of Birth Date Format: MM slash DD slash YYYY Insurance Information (please include Member ID):Billing Address Associated With Insurance Plan: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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?TelehealthIn PersonIf no in person appointments are available, would you be open to Telehealth?YesNoIf you prefer to be seen in-person, do you wish to come to our Center City Philadelphia or Jenkintown location?JenkintownCenter CityWe have a trained therapy dog in the office at times. Please let us know if you have a fear of dogs or are allergic.Are 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 Accepted file types: jpg, gif, png, pdf, jpeg. **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**
