Child Psychological Services: Request Appointment

Please fill out the information below to request an appointment and we’ll get back to you shortly.

"*" indicates required fields

Name*

First Last

Name of child receiving services:*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Email*

Please select which service interests you:*

Outpatient Therapy Clinic – Wexford location

Outpatient Therapy Clinic – Bridgeville location

Intensive Behavioral Health Services (IBHS)

Diagnostic Testing – Wexford location

Please indicate the age of the child receiving services:*

Please note that we provide services for children ages 5 to 21.

Please indicate if the child receiving services is insured by the following:

Type of Insurance:

If you selected Medical Assistance, please indicate the county in which you reside:

Additional Information

If you have additional information, please add it here.