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
Ann Gantt: Willow Street, all ages, daytime hours
Multiple Providers: Telehealth, adults, daytime hours

Estimated wait times (Updated September 2025)
Children 6-9 months
Adults In-Person, Evening: 3-6 months
Adults Other: 0-3 months

A counselor for every concern.

Availability to meet your needs.

Client Name (Full Legal Name)

Client 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

Thank You

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Willow Street Location

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