Lasting Wellness Appointment Request

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number

Area CodePhone Number
Insurance (Geisinger, Highmark, Aetna, Optum, United Behavioral Health, etc.) *
Subscriber ID for Insurance
When are you generally available for appointments? *
Please let us know if you have a specific therapist you would like to work with.
We offer both in person sessions and telehealth. Please let us know if you have a preference.
What would you like to work on in therapy? *
How did you hear about our services?
Thank you for filling this out. If you do not hear back from us in one business day, please check your spam/junk folder.
Should be Empty: