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 StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Please note which services interest you:You can choose multiple services in the check boxes below. Social Skills Group Therapy Individual Therapy Diagnostic Evaluation Neuropsychological Testing Evaluation Wraparound Evaluation Wraparound Services Medication Management Summer Camp Other 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.
