Request an Appointment | Shadyside Office

Preferred Therapist Name

Name*

First Last

Email*

Phone*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Gender*

Date of Birth*

Insurance

Other Insurance

Insurance Member ID

Insurance Group Number

Contact Preference*

Please select the type of service you would like to schedule:*

Please tell us when you are available:*

Seeking help for/with

How did you hear about us?

Please select the option that best describes your referral source

Please elaborate:

Please provide your specific referral source

Phone

This field is for validation purposes and should be left unchanged.