Intake FormCCCadmin2023-12-27T18:00:26+00:00 Intake Form Please enable JavaScript in your browser to complete this form.Name *FirstLastPronounsShe, Her, HersShe, Her, HersHe, Him, HisThey, Them, TheirsZe, Hir, HirsNo PronounsNo PreferenceNot ListedEmail *Phone Number *Location of Choice *Wexford (with optional Telehealth appointments)Squirrel Hill (with optional Telehealth appointments)Counselor of Choice in Squirrel Hill *Director's recommendationCatia Fath, NCC, LPCJennifer Black, LPCJennifer Matesa, LCSW, MFAKatyana Gradler, LCSWKelly Horvath, LSWAmanda Buchheit, LPCDaiDra Thompson, LPCCate Axtman, MSCP,LAPC, JDGeorge Dalzell, LCSWAmanda Holmes, LPCDanielle Witmer, NCC, LPCIf no choice is made, the director will make a recommendation.Counselor of Choice in Wexford *Director's RecommendationCatia Fath, NCC, LPCNicole Metger, LPCJessica Peluso, LPCAmanda Buchheit, LPCIf no choice is made, director will make a recommendation.Briefly describe why you are seeking help. *Insurance (We do not accept Medicare or Medicaid.) *AetnaBlue Cross/Blue ShieldEvernorth (Cigna)HighmarkUnited HealthcareUPMC CommercialOtherSelf PayFront of Insurance Card Click or drag a file to this area to upload. To help with coverage determination, please upload a picture of the front of your insurance card.Back of Insurance Card Click or drag a file to this area to upload. To help with coverage determination, please upload a picture of the back of your insurance card.MessageSubmit More Questions? Call (412) 229-7353 Email Creating Connections Counseling
