New Client Information Form

Please correct the errors described below.

Updated 10/5/2020

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

  • If you have Medical Assistance, Capital Blue Cross, or another BC/BS plan (not Highmark), or Quest, AND 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 a different insurance plan than the plans listed above, or if the client is 7 or under, please check back later. All of our therapists who are credentialed with other insurance plans, 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 http://CampbellPsychPA.com/forms for a Referral Form. Thank you!

PLEASE NOTE: We do not have evening hours and afterschool appointments are extremely limited. **Completing this form does not guarantee an appointment.**

Information About Client

Please be sure to choose the correct year

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/custody for more information.

Insurance / Payment

Insurance **We currently have openings for Medical Assistance, Capital Blue Cross, and Other BC/BS (not Highmark) clients only**

We are in-network with several insurance plans. 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)

Additional Insurance

Scheduling

Thank you! We will review the information provided. If you have Medical Assistance, Capital BC, or another BC/BS plan (not Highmark) and the client is at least 8 years old, we will be in touch within 1-2 business days.

Your information will be encrypted.

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