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Matters of the Heart Counseling, LLC

This form is a request for an appointment and not a guarantee of services.

Telephone717-282-2908

First name

Last name

Email address

Phone number

Client Name if different from yours

Client Date of Birth

Brief reason for seeking services

Name of Insurance or Self Pay

We are in network with Highmark, Blue Cross (in and out of areas), Quest, Medical Assitance, Geisinger. Other insurances we may be able to help you secure out of network benefits.

Insurance Member/Policy Number

Having your insurance information allows us to verify benefits

This is only a request for services and not a guarantee of availability nor does it create a client-therapist relationship. Please allow 3-4 business days for a response.

Therapist Preference

Hillary Bossert-Davis, LCSW Michael Osborne, LPC Casie Fisher, MA Macy Stanley, MA, NCC Christy Ranco, MA, NCC Nicole Hess, LSW Dan Grubb, LPC Courtney Hammer, ATR-BC, LPC Karen Mummau, LCSW Rebekah Patrick Becker, LPC Megan Boudreau, Intern Steph Todoroff, Intern Art Therapist Any Available I would consider an intern at a reduced rate

How Did You Hear About Us?

website Psychology Today Referral from Friend Referral from PCP Google Other

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Matters of the Heart Counseling, LLC

This form is a request for an appointment and not a guarantee of services.

Telephone717-282-2908

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