Language
English (US)
Español
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please include area code.
Email
example@example.com
Location
*
Pennsylvania
Washington, DC (DMV)
Georgia
Other
Back
Next
Save
Please answer the following questions for the person who will be receiving services.
Do you have insurance?
*
Yes
No
Other
My desired payment method:
*
Medicaid
Self-Pay
Other
I am experiencing challenges with:
*
Depression
Addiction
Anxiety
Anger Management
Grief or Loss
PTSD/Trauma
An LGBTQ+ Related Issue
A Family Situation or Difficulty
Phobias
An Eating Disorder
ADD/ADHD
Other
Preferred Appointment Type
*
Telehealth
In-Person
Back
Next
Save
I learned about Preventive Measures from...
*
A Healthcare Provider
An Insurance/Agency Website
Google/Internet Search
A Radio Ad
Social Media
A Friend or Current Client
Community Event/Outreach
Community Liaison/PM Employee
Other
Please specify the name of your Healthcare Provider or Insurance/Agency Website
Are you interested in learning about Home Health Care Services or employment for you or a loved one? (Pennsylvania only)
Interested in Services
Interested in Employment
No interest at this time.
Please check the box to verify you are human.
*
Save
Submit
Should be Empty: