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 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 Medication Management Intensive Behavioral Health Services (IBHS) Summer Camp Other Please select the apprropriate age range of the child receiving services:* 1-5 years old 6-13 years old 14-18 years old 19-21 years old 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.
