Get in Touch

NOTICE: This message will be sent to the office administrator and will be forwarded to the appropriate provider. Please do not share personal medical information on this form.

*If you have a medical emergency, please call 911*

Contact Us

Location

2940 South Park Rd

Bethel Park, PA 15102

Phone : (412) 833-1800

Fax: (412) 833-1818

Hours by Appointment

MONDAY – FRIDAY : 8:00 – 8:00

SATURDAY: Closed

SUNDAY: Closed

Contact Us Form

This field is hidden when viewing the form

Next Steps: Sync an Email Add-On

To get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.

About You

Your Name(Required)

First Last

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Best Day to Call You

Best Time to Call You

What County Do You Live In?

Which county in Pennsylvania do you reside?

Patient's Information

If you are contacting us on behalf of someone else, please provide their information.

First Name

Patient's First Name

Last Name

Patient's First Name

Date of Birth(Required)

Type of Counseling(Required)

Choose the type of counseling you are interested in.

Insurance Information

Please provide any Insurance Information.

Insurance Carrier(Required)

UPMC

Highmark

Blue Cross Blue Shield

Aetna

United Healthcare

Medicaid (must live in Allegheny County)

Medicare

Other

Choose your Insurance Carrier

Preferred Therapist

Please indicate if you have a preference on the therapist you would like to or working with.

Type of Session(Required)

Please indicate your preference

Comments

Please leave a brief message regarding your interest and needs. Please do not share private or explicit medical information.

Phone

This field is for validation purposes and should be left unchanged.

Please contact your insurance company and ask these questions.

What are my mental health insurance benefits?
How much is my deductible, when does it begin, and has it been met?
Is there a limit on how many sessions my insurance will cover?
What is my copay and is it the same amount for teletherapy and in person sessions?
Is approval or referral required from my primary care physician?