Request Appointment

IF YOU ARE IN CRISIS OR FEELING SUICIDAL, CALL 911 IMMEDIATELY–CLICK HERE FOR ADDITIONAL RESOURCES

Current patients, please call 610-626-8085 ext. 1001 for scheduling inquiries

Personal Information

First Name (required)
As it appears on your insurance card, if you have one.

Last Name (required)

If you are filling this form out for someone under the age of 18, please give your full name
and relationship to the patient:

Your email (required)
*Please add intake@psychchoices.com to your address book to avoid responses being directed to your SPAM folder.

Main Phone #: (required) To Opt-In for SMS/Text Messaging with Psych Choices, please check box here. Yes
For more information, please visit www.psychchoices.com/SMSprivacyTermsAndConditions/

Second Phone #:

Address: (required)

City: (required)

State: (required)

Zip: (required)

Date of Birth: mm/dd/yyyy: (required)

Best Time to Call: 8 - 3 M-F preferably: (required)

Gender: (required)

Preferred Appointment Day & Time:

Emergency Contact Name: (required)

Emergency Phone: (required)

We can't guarantee that we can accommodate your preferred time

BRIEF ASSESSMENT AND HISTORY

Service Requested: (required)

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Choose a Therapist Provider (required)
*Please note we cannot guarantee provider availability and will offer an alternative provider based on your service needs if the one you’ve chosen is not available.

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Choose a Medication Provider (required)
*Please note we cannot guarantee provider availability and will offer an alternative provider based on your service needs if the one you’ve chosen is not available.

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If we do not have a therapist available who is in your insurance network, would you be interested in seeing a master's level, low-cost counselor at a flat rate of $60 per visit? (required)YesNo
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Service Type (required)

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I need help with: (required)to select multiple options press CTRL first before clicking
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Other:
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I ... (required)

In regards to psychiatric medications: (required)

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Antidepressants & Anxiolytics: to select multiple options press CTRL first before clicking

Mood stabilizer & Antipsychotics: to select multiple options press CTRL first before clicking

Sleep aids to select multiple options press CTRL first before clicking

Stimulants: to select multiple options press CTRL first before clicking

Other

**We do not prescribe long term use of the following classes of medications, if you are currently on any of these medications, you will need to continue to have it prescribed by the current prescriber or seek medication management elsewhere.
Benzodiazepines: Xanax (alprazolam), Ativan (lorazepam), Valium (diazepam), klonopin (clonazepam) *

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In regards to drugs/alcohol: (required)

In regards to being being treated in the ER or hospitalized for mental health issues… (required)

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Please Note Regarding Disability Evaluations: Psych Choices does not complete disability evaluations. Our providers generally require you to be under their care for 6 months or more before they will indicate any type of mental health diagnosis for the purpose of disability documentation.

Please Note Regarding Court Ordered Treatment: Psych Choices does not complete court ordered nor substance abuse evaluations. We do not testify in court and recommend you referring to legal counsel for such matters.

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Insurance Information

Please note we cannot accept Keystone Mercy, Keystone First, Aetna Better Health, Access, United Healthcare Community Plan, or any other Medicaid plan. If you have this type of insurance, either as primary or secondary coverage you may want to contact Crozer Chester Medical Center Behavioral Health

We do accept most major commercial insurances, including Medicare. Please note, if you are QMB (Qualified Medicare Beneficiary) we are unable to accept your plan as we are not enrolled in Medicaid.

Primary Insurance Plan: (required)

Primary Insurance Id: (required)

Secondary Insurance Plan:

Secondary Insurance Id:

If you add a secondary plan name, then add the ID # too

Policy Holder's Name: (if not patient)

Insurance Phone: (required)

Please enter the phone number on your insurance card for Mental or Behavioral Health, if there is one. If none, then enter the phone for providers to call
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Finish It Up

Any Additional Comments:

How Did You Hear about Us?:

Other Referral Source:

Thank you for completing this form to the best of your ability. If the information is sufficient, we will be contacting you via email to let you know when your appointment is scheduled.

If we need further information or to discuss anything with you, we will try to reach you by phone.

In any case, you will be hearing from us within 1 to 3 business days. Feel free to contact us at intake@psychchoices.com if you have any questions or concerns.

Please note that emails sent through this page are no more secure than emails sent through any other email program. But this page is HTTPS encrypted. You may want to limit what you say in your email. Please do not use email to convey personal information. Please be aware that this email will be read by our office staff.