Request An Appointment

To request an appointment, please fill out the form below. Once your request is submitted you can expect to be contacted within one business day.

Estimated wait times (Updated March 2023): 
Children: 12 months
Adolescents: 9 months
Adults In-Person: 6-9 months
Adults Telehealth: 2-3 months
Evening requests for all ages may be longer than the estimates above.
We are unable to accommodate any medical assistance plans at this time.

A counselor for every concern.

Availability to meet your needs.

Client Name

Client Age

Pronouns

Contact Name (if different)

Contact Email

Contact Phone Number

Referred By

Name of Insurance Company (Note that we do not accept Medicare plans)

Does Your Insurance Go Through Medical Assistance (Medicaid) or CHIP? We are unable to accommodate new Medical Assistance requests at this time.

Employee Assistance Program (EAP) Name and Information (if applicable)

Reason For Counseling

Do you prefer a telehealth session (via a confidential, HIPAA compliant video chat software) or an in person session?

Preferred Time

Getting in the door quickly is more important to me than my location/time preferences

If there is anything else we should know before sending your information to a therapist, please add it below

Emergency Information:
If you feel that you or a loved one are in crisis:
Call 911 or go to the closest emergency room
Call Crisis Intervention at 717-394-2631

Request An Appointment

Thank You

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Willow Street Location

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