Schedule Therapy Visits | Pottstown, PA

Request An Appointment Form

Name of Prospective Patient

Name of Prospective Patient

First

Middle

Last

Contact Email

May we send email to this address regarding appointments/scheduling?

Yes

No

Date of Birth

How were you referred to us?

Marital Status

Employment

Education

Assigned sex at birth (This information is for health insurance purposes.)

Contact Information

Contact Information

Free Text

If the patient is under 18 years old please provide their parents information

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Cell Phone

May we leave a message at this number?

Yes

No

Field label

If the patient is 13 years old or younger, and there is joint legal custody, consent from both custodial parents/guardians is required prior to the initial appointment.

Mother

Custody

Father

Parent's Marital Status

Describe briefly the reason you are requesting an appointment.

Do you have any issues with drugs or alcohol?

Yes

No

If yes, is it current or past?

Current

Past

If drug use is current, what type of substance?

Insurance Information

Insurance Information

Insurance Plan

Insurance ID #

Group #

Free Text

Policy Holder's Name

First

Last

Mental Health Phone #

These phone numbers can be found on the back or front of your insurance card.

Mental Health Phone #

Customer Service Phone #

Holder's Employer

Policy Holder's DOB

Policy Holder's Relationship to Patient

Indicate your availability to attend weekly appointments:

Mornings

Afternoons

Evenings

Elaborate on your availability, for example, after 5 PM or before 3 PM.

Select your location(s).

Pottstown

Collegeville

Montgomeryville

Do you prefer telehealth, in-person or either one?

Person Completing this form

First

Last

Request an Appointment for Personalized Mental Health Care

Request An Appointment Form