Request an Appointment Please fill out the information below to request an appointment and we’ll get back to you shortly. Name* First Last Name of child receiving services:* First Last Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Please select which service interests you:* Outpatient Therapy Clinic - Sewickley location Outpatient Therapy Clinic - Bridgeville 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:Medical AssistanceParents' InsuranceBoth Medical Assistance and Parents' InsuranceOtherType of Insurance:Medical AssistanceBlue CrossUPMCOtherIf you selected Medical Assistance, please indicate the county in which you reside: Additional InformationIf you have additional information, please add it here.
