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Contact Form

Reach out today to discuss your needs and find the support that’s right for you.

(570) 534-0577, FAX: 484-282-9607

[email protected]

Telehealth available in Pennsylvania.

First Name

Last Name

Date of Birth

E-mail Address

Phone Number

Age

Social Security Number

Address

Current Insurance plan Name and ID or Self Pay

Purpose of Consultation

Have you ever been diagnosed with a mental health disorder?

If yes, what were you diagnosed with and the year

Do you currently take prescribed medication?

Or have taken medication in the past?

If you answered 'Yes', what medication are you taking and when was it last prescribed

Have your ever had any psychiatric emergency room visits or psychiatric hospitalization?

When and where were you hospitalized

Are you currently abusing a substance?

If you answered 'Yes', what did you use? And when was the last time you used?

I currently accept. I believe it was on the content form I originally sent you.