“Happiness by Choice, Not by Chance”

Request an Intake Appointment, for New Patients Only

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Please complete the following form and click "Send." If you do not hear from us within 3 business days, please check your junk folder for a response from Intake@PsychChoices.com and also feel free to call us at 610-626-8085.

Existing Patients, please use the contact page or call your therapist to request an appointment.

If you are new to Psych Choices, or have not been seen here in more than a year, please complete this form in its entirety. You will generally receive a response by email in 2 to 3 business days, though it may take a little longer at times. Please understand that although you may request a specific provider, time and date, you do not have an appointment until you hear from our Intake Coordinator and respond to her as instructed to reserve your appointment.

Your first appointment may be scheduled as soon as a week from your first request, or it may take as long as a month or more, especially if you are seeking psychiatric medications. If your need is urgent, please contact your primary care doctor, or your county's mental health emergency services (in Delaware County you may contact the Mobile Crisis Line at 855-889-7827). You may also call 911 as needed in a mental health crisis.

Please Note: that if you are looking for psychiatric medications, you may not always receive a prescription at your first session. It is common for our doctors to request lab work, including but not limited to general blood tests, genetic testing to help select appropriate medications, and/or urine drug screens, before prescribing for you. In that case it may not be until your second visit, which is often one to 4 weeks later, that the medications will be prescribed for you. If this is a problem for you please let us know on this form, or by phone or email.

Request Your First Appointment

Personal Information

Select a Provider:

Your Email Address: *

First & Last Name: *

As it appears on your insurance card, if you have one.

Main Phone #: *

2nd Phone #:

Address: *

City + State: *

Zip Code:

Best Time to Call: 8 - 3 M-F preferably*

Date of Birth: mm/dd/yyyy*

Gender: *

Preferred Appointment Day & Time:

We can't guarantee that we can accommodate your preferred time.

Emergency Contact Name: *

Emergency Phone: *

Insurance Information

Please note we cannot accept Keystone Mercy, Keystone First, Aetna Better Health, Access, United Healthcare Community Plan, or any other Medicaid plan. If you have this type of insurance you may want to contact Crozer Chester Medical Center Behavioral Health.

We do accept Medicare, and most major commercial health insurance plans.

Primary Insurance Plan: *

Primary Insurance ID #: *

Secondary Insurance Plan:

Secondary Insurance ID #:

If you add a secondary plan name, then add the ID # too

Policy Holder's Name: (if not patient)

Insurance Phone:

Please enter the phone number on your insurance card for Mental or Behavioral Health, if there is one. If none, then enter the phone for providers to call

Brief Treatment History and Goals

Briefly explain what type of issue(s) you are seeking treatment for: (Examples: Depression, Anxiety, Child Behavior, Marriage Counseling)

Are you currently in psychotherapy?: Yes No

Are you currently taking any psychiatric medications? : Yes No

If so are you currently prescribed any benzodiazepines?: Yes No

Do you have any drug/alcohol abuse issues?: Past Currently No

Is Treatment Court Ordered?: Yes No

Please note, we do not do court evaluations. We do not testify in court, and we do not do substance abuse evaluations.

Are you applying for disability & need paperwork done?: Yes No

Please note: We do not do disability evaluations

Finish It Up

Any Additional Comments:

How Did You Hear about Us?:

Other Referral Source:

Anti ~~SPAM~~ Question*What PA county/valley are we in?

(* - REQUIRED FIELDS)

Thank you for completing this form to the best of your ability. If the information is sufficient, we will be contacting you via email to let you know when your appointment is scheduled.

If we need further information or to discuss anything with you, we will try to reach you by phone.

In any case, you will be hearing from us within 2 to 3 business days.

Please note that emails sent through this page are no more secure than emails sent through any other email program. But this page is HTTPS encrypted. You may want to limit what you say in your email. Please do not use email to convey personal information. Please be aware that this email will be read by our office staff.