Please fill out this online intake form to start the appointment process and our office will follow up with you in 24 to 48 hours. In case of an emergency, please call 911. Please enable JavaScript in your browser to complete this form.Your Name *FirstMiddleLastEmail *Phone *Would you like to complete your intake form online? *YesNoOur online intake form is confidential and secure. It is sent directly to a password protected and encrypted server. We do not sell, rent or otherwise disclose personal information collected by our site to any third parties. Your data is for intake purposes only and is only accessible by designated administration staff. If you have any questions, please call 412-366-1300.Preferred contact method for appointment reminders *Phone CallTextEmailAre these services for yourself? *YesNoWho are these services for? *Please include relationship and nameAge *Gender Assigned at Birth *MaleFemaleWe require the following information for communicating with your insurance provider, understanding our population better and fulfilling our grant reporting requirements. INSURANCE: Please make sure the gender you provide here is the same as what your insurance provider has on file. If you would like to tell us more about your gender identity so that we can better communicate in the most respectful way while addressing you, please use the next field. Gender IdentityMarital Status *SingleMarriedSeparatedDivorcedWidowedI am interested inIndividual CounselingCouples CounselingFamily CounselingSelect all that applyAddress (Street) *Address (City, State, Zip) *MunicipalityHousehold Size *How many people are in your household?Referral Source *Insurance CompanyAnchorpoint's WebsiteChurch/ParishSchoolFormer ClientAnchorpoint StaffFamily MemberFriendSocial MediaPsychology TodayNorth Hills MonthlyGoogleNorthern ConnectionsGood TherapyOtherHow did you hear about us?If other please explainIf you are a former client, who was your counselor?Best day(s) for counseling *MondayTuesdayWednesdayThursdayFridayBest time(s) for counseling *8am-12pm12-2pm2-5pm5-8pmAreas of Concern (Check all that apply) *DepressionAnxietyAngerSchool ProblemsLegal IssuesFamily ConflictBereavement/GriefSpiritual ConflictAddictionHistory of AbuseMarital ProblemsDivorce/SeparationInfidelityMilitary/First ResponderPTSDLGBTQ+OtherIf other please explainHave you ever seen a counselor before? *YesNoHow long ago? *1-2 years2-5 years5-10 years10+ yearsDo you have insurance? *YesNoNo matter if you have insurance or are uninsured, we are here to help.What insurance do you have? (OPTIONAL)AetnaHighmarkAnthem BCBSMagellan Blue ShieldBlue Cross/Blue ShieldMedicareCoventry/Advantra (MHNet)United HealthcareCigna/Cigna InternationalUPMCWe are here to work with you if you do not have insurance or are under-insured. We will follow up to discuss an affordable payment option.Would you like to receive our Monthly E-Newsletter to learn how to get more from your experience with Anchorpoint? *YesNoWebsiteSubmit
