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.

Availability
We are accepting new clients of all ages at both locations and via telehealth.We have a few evening openings that we expect to fill quickly.

Updated 5/12/26

A counselor for every concern.

Availability to meet your needs.

Client Legal Name

Date of Birth

Pronouns

Contact Name (if different)

Contact Email

Contact Phone Number

Referred By

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

Insurance ID Number

Insurance Group Number (if applicable)

Insurance Member Services Phone Number

Does Your Insurance Go Through Medical Assistance (Medicaid) or CHIP?

Employee Assistance Program (EAP) Name

EAP Authorization Number/Code (if applicable)

Reason For Counseling

Do you prefer a telehealth session (confidential, HIPAA compliant video call) 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

Willow Street Location

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