Referral Form

Please complete the form below to get started

Quick notes:

I do not offer late afternoon or evening appointments, daytime only.

I am not in network with Independence Blue Cross, Independence Administrators, or Keystone Health Plan East. Please check your card prior to selecting Blue Cross/Blue Shield on the form below. Please don’t assume that you don’t have Out of Network reimbursement through your plan. I am happy to help you figure out the reimbursement process if you are eligible for those benefits.
Appointments are virtual only.

How did you find me?

Name

First Name

Last Name

Phone

(###)

###

####

Email Address

Age

Gender

Non-conforming, non-binary welcome

Availability

What is your availability like for a telehealth appointment? For example: days./times where you will have online access in a quiet, private setting?

Focus

Please explain your greatest need, or what you'd most like to get out of online therapy at this time. I like to be effective/do my job well, so it's very helpful for me to understand your focus.

Please select your method of payment for services

Please look carefully at the insurances below. *Independence Blue Cross/Personal Choice and Keystone Health Plan East are not the same as Blue Cross/Blue Shield.

Insurance- Blue Cross/Blue Shield

Insurance- Aetna

Insurance- United Behavioral Health/Optum

Insurance- Medicare

Out of Network Reimbursement: Cigna, Personal Choice, Keystone

Private Pay

Emergency

I understand that if I am having thoughts of harming myself or others that I need to call 911 or go to my nearest emergency room. This form is not a consent nor a guarantee for treatment.

Yes, I understand

Additional information

Please include any other information you feel is important for me to know.