Book An Appointment — Pediatric Counseling Services

New patient appointments

Please complete the information below so we can begin the scheduling process. Once we review the information, we will contact you via phone to gather any additional information needed and discuss scheduling options.

Please feel free to contact our office with any questions at 412-388-0880.

Parent/Guardian Contact Information

First Name

Last Name

Phone

(###)

###

####

Home Address

Name of Patient and Date of Birth

Primary Insurance Information

Please provide Primary Insurance Type, ID number, Subscriber and Subscriber DOB

Secondary Insurance Information (If applicable)

Please provide Secondary Insurance Type, ID number, Subscriber and Subscriber DOB

Please describe briefly why you are seeking counseling and areas of concern

Who were you referred by?