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Restoring Balance, Renewing Hope.

Are you in the state of Pennsylvania in the United States of America? *YesNo

What type of therapy are you interested in?IndividualCouplesFamily

I prefer a therapist with experience in:ADHDAnxietyAutismBehavioral Disorders in ChildrenBi-PolarDepressionEating DisorderGrief and LossLGBTQ+ IssuesObsessive Compulsive DisorderPost PartumTrauma

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First Name *

Middle Name

Last Name *

Email Address *

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Phone Number *

How do you wish to be contacted? (Phone, or Email)

Date of Birth

What brings you here:0 / 180

Do you prefer:No preferenceIn-person sessionsVirtual/Remote Sessions

What is your general availability?Open availabilityDayNightWeekends(limited)Weekdays

Are you interested in using your insurance:YesNo- Self-pay (Self-pay rates are $200 for 60 minute sessions)

If you are using insurance, provide your insurance carrier name(s): Primary Insurance *

Primary Insurance Member ID Number: *

Primary Insurance Group Number *

If you currently have a Secondary or Supplemental Insurance, please enter carrier name:

Secondary or Supplemental ID Number