We would love to hear from you.

The form below provides all the information that we need to know in order to best assist you in scheduling an appointment and pairing you with the right therapist on our team!

ForensicCounselingAssociates@gmail.com
P: (570) 476-7704
F: (570) 421-3600

Name

First Name

Last Name

Email Address:

Phone Number:

(###)

###

####

Summary of Presenting Concern:

Briefly describe the main issue or concern you would like to address in therapy.

Preferred Therapist:

If any, select your preference for a specific therapist at our practice or if there is a preference for a Male or Female therapist.

Insurance Provider:

Please provide the name of your insurance provider. Please note we do not accept Medicare insurance and Medicaid insurance that we accept can vary.

Session Preference:

In Person Session

Telehealth Session

Office location preference for in person sessions (if applicable):

Mt. Pocono

Moosic

Session Frequency:

Weekly

Biweekly

Preferred Days/Times for Sessions:

Preferred Method to Contact You (email, phone call, text):