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Wellness Works Counseling
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Are you in the state of Pennsylvania in the United States of America?
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Therapists at Wellness Works Counseling are licensed in the state of Pennsylvania and the country of the United States of America. If you are physically located in a state outside of Pennsylvania in the United States of America, consider contacting counseling services in your area. There is current pending legislation that may open services in the future. This form will be updated when expanded services are possible.
Yes
No
What type of therapy are you interested in?
Individual
Couples
Family
I prefer a therapist with experience in:
ADHD
Anxiety
Autism
Behavioral Disorders in Children
Bi-Polar
Depression
Eating Disorder
Grief and Loss
LGBTQ+ Issues
Obsessive Compulsive Disorder
Post Partum
Trauma
Prefix
Mr.
Mrs.
Ms.
Mx.
Miss
Dr.
Prof.
First Name
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Middle Name
Last Name
*
Email Address
*
Confirm Email Address
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Phone Number
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How do you wish to be contacted? (phone, text, or email)
Date of Birth
What brings you here:
0 / 180
Do you prefer:
No preference
In-person sessions
Virtual/Remote Sessions
What is your general availability?
Open availability
Day
Night
Weekends(limited)
Weekdays
Are you interested in using your insurance:
Yes
No- Self-pay (Self-pay rates are $200 for 60 minute sessions)
If you are using insurance, provide your insurance carrier name(s): Primary Insurance
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Primary Insurance Member ID Number:
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Primary Insurance Group Number
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If you currently have a Secondary or Supplemental Insurance, please enter carrier name:
Secondary or Supplemental ID Number
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