Book An Appointment — Sparrow Therapeutic Services

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Can we leave a voicemail at this number?

What services are you interested in?

Individual Adult (18 & Older)

Individual Adolescent (12-17)

Couples

Family

Group

Insurance

Please select your insurance provider from the list below or write in your insurance provider using the "other" field. If you are offered and accept an appointment, you will be asked to register as a new member via our practice's online patient portal. Once your registration is complete, we will verify your insurance and will send your expected co-pay in the confirmation email that goes out before your first session. *** Please be advised that we, unfortunately, do not accept Keystone First or Medicaid insurances, at this time. If you have any questions about your coverage, please call the number on the back of your insurance card and inquire about your benefits for outpatient mental health office services.

Other:

What days work best for you? (check all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What times work best for you? (check all that apply)

Morning (9:00am-12:00pm)

Early Afternoon (12:00pm-3:00pm)

Late Afternoon (3:00pm-5:00pm)

Early Evening (5:00pm-7:00pm)

Evening (7:00pm or later)

Presently, services are offered via teletherapy only. Are you ok with virtual therapy?

Please select one

Do you prefer a male or female therapist?

Which member of our team are you interested in working with?

Please write your Member ID as it appears on your insurance card (include alpha prefix, if applicable). Please write your Member ID as it appears on your insurance card (include alpha prefix, if applicable).

if you selected EAP from the list above, please provide your authorization number. Write N/A if you do not plan to use insurance

What state do your currently live in?

*Please be advised that, presently, we can only offer services to permanent residents of Pennsylvania and Delaware.

How did you hear about us?

If you are filling this out on behalf of someone else, please share your name, email address, phone number, and relationship to the potential member.

Let’s create your masterpiece!