Request An Appointment We’re glad you’re here—please share a bit about what you are looking for, and our team will follow up shortly. Full NameDate of Birth MM slash DD slash YYYY GenderEmail PhoneBest way to reach you:What type of services are you seeking?Select the option that best fits your needs. If you’re unsure, we’re happy to help guide you.Therapy (individual, couples, or family)Psychological / Forensic EvaluationPsychiatric Evaluation / Medication ManagementA combination of servicesNot sure — I’d like someone to help me determine thisWhat type of psychological/forensic evaluation are you seeking?Psychoeducational/ ADHD/ ASDForensic/ Court-related, Act 235Psychological/DiagnosticNot SurePlease briefly describe what brings you in at this time.A few sentences is perfect—what’s been going on recently, and what kind of support you’re hoping for.Do you plan on using insurance?NoNot sureYesInsurance Company Name and Member ID NumberBilling 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: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. Recurring Availability (i.e.: days of week/ times of day available for appointments):Are 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?**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**