Appointment Request

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Updated 11/5/2020

WELCOME! If you are interested in scheduling an intake appointment, please read this introduction carefully.

  • If the potential client is at least 8 years old, please complete the form below. Our Client Care Coordinator will be in touch within 1-2 business days.

  • If you have Highmark, Federal BC, or TRICARE, or if the client is 7 or under, please check back later. All of our therapists who are credentialed with those insurances, and who see younger children, are currently full.

All intake appointments are via telehealth (video) due to the COVID19 pandemic. We encourage you to review our Frequently Asked Questions before completing this form, http://CampbellPsychPA.com/FAQ . If you prefer to speak with someone by phone, our Coordinator can be reached Mon-Thurs from 10 AM - 2 PM, at (717) 422-6440, option 1.

This form is for use by potential clients/families only. If you are a third party who is interested in referring a client to us, please visit CampbellPsychPA.com/forms for a Referral Form. Thank you!

PLEASE NOTE: We do not offer evening appointments. Afterschool appointments are extremely limited. *Completing this form does not guarantee an appointment.**

Contact Information

Information About Client

Other Parent Information

If there is shared legal custody, we will need contact information for all individuals who share custody so that we can reach out to them to obtain consent. Visit http://CampbellPsychPA.com for more information.

Insurance / Payment

Insurance

We are in-network with several insurances. If your child is covered by more than one insurance policy, please provide information for EACH policy. If we are not in-network with your insurance, we are happy to provide services out-of-network. This means that you are responsible for paying our full fee at the time of service, and we will provide you with paperwork to submit to your insurance company for potential reimbursement. For more information about our rates and payment options, please visit http://CampbellPsychPA.com/rates-insurance.

Insurance Policy #1 (Primary Insurance)

Insurance Policy #2 (Secondary Insurance)

Please check here if the client does NOT have a secondary insurance. If the client does have a second plan, please provide the information below.

Additional Insurance

Scheduling

Thank you! We will review the information provided. If you meet the requirements for our current openings (age, insurance), we will be in touch within 1-2 business days.

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