Request an Appointment | Shadyside Office

Preferred Therapist Name
Or select Therapist, or second preference, from dropdown
Name*
First Last
Email*
Phone*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Gender*
- Male
- Female
- Rather Not Say
Date of Birth*
MM slash DD slash YYYY
Insurance
Other Insurance
Insurance Member ID
Insurance Group Number
Contact Preference*
- Email
- Phone
Please select the type of service you would like to schedule:*
- Individual
- Couples
- Family
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
Name
This field is for validation purposes and should be left unchanged.