Child Psychological Services: Request Appointment

Please fill out the information below to request an appointment and we’ll get back to you shortly.

Name*
First Last
Name of child receiving services:*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email*
Please select which service interests you:*
- Outpatient Therapy Clinic – Sewickley location
- Outpatient Therapy Clinic – Bridgeville location
Please indicate the age of the child receiving services:*
Please note that we provide services for children ages 5 to 21.
Please indicate if the child receiving services is insured by the following:
Type of Insurance:
If you selected Medical Assistance, please indicate the county in which you reside:
Additional Information
If you have additional information, please add it here.

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