New Patient Request Step 1 of 14 7% At this time our office offers daytime appointments only for new clients. We do not offer evening (4pm and later) or weekend appointments as those are highly sought after and limited spots are designated for current clients. Please acknowledge below that you have read and understood that appointments with our office would have to be daytime only during the week:(Required) I acknolwedge Patient InformationPatient Name(Required) First Last Patient Date of Birth(Required) Month Day Year Current Age of Patient(Required)If patient is under the age of 18, is there a custody agreement filed with the courts?(Required) Yes No N/A, Patient is over age of 18 Please note: adolescents over the age of 14 may consent to their own mental health treatment in PA. However, if there is a court order of joint legal custody, then the consent of both parents is required. Therefore, we screen all minors for custodial arrangements. CBI requires a copy of the order to be provided to our office prior to scheduling. The custody order must be reviewed by our clinical director to determine who needs to consent for treatment for the minor. Please upload a copy of the custody agreement to continue initiating care for your child:(Required) Drop files here or Select files Max. file size: 50 MB. Name of Legal Guardian initiating care for minor patient:(Required) Name of all current legal guardians of the minor patient, their relationship to the patient, and their contact information (either phone number or email address):(Required)Which legal guardian(s) plan on attending this initial appointment with the minor patient?(Required) How did you hear about Cognitive Behavior Institute?(Required) Google Search PCP/Pediatrician Current CBI Patient CBI Staff Member Insurance Quartet Zocdoc Psychology Today OpenAppointments.net School Court Order IOP/PHP Hospital/ER Therapist Psychiatrist EAP Facebook Freespira Commercial Good Therapy NASW Gottman Referral Network Other Name of referring provider/office (PCP/Pediatrician, IOP/PHP, Hospital, Therapist, Psychiatrist, CBI Staff Member):(Required) A copy of the court order must be sent to our office prior to scheduling an appointment. Not all court orders are appropriate referrals for CBI. Please have the court order emailed to [email protected] or faxed to 724-299-8964.(Required) I agree to ensure that the court order is sent via email or fax to determine if CBI is able to provide the services needed. DisabilityAre you seeking disability paperwork from a CBI provider?(Required) Yes No I understand that I am unable to request a consideration for disability paperwork to be filled out by any psychiatric provider at CBI until I have been a client under care of the psychiatric provider for at least 3 months.(Required) I understand Workers CompensationIMPORTANT: Please note CBI is unable to accept Workers Compensation claims.(Required) I understand Social SecurityIMPORTANT: Please note that CBI is unable to provide evaluations and/or services for pursuit of social security benefits.(Required) I understand Contact InformationPhone(Required)Email(Required) Home Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance and PaymentPlease note: CBI is not in network with any Medicaid/Medical Assistance insurance products, including but not limited to: CCBH, UPMC For You, United Community Plan, Aetna Better Health, Highmark Wholecare, Gateway, and VBH. Additionally, CBI is unable to accept Medicare/Medicaid DUAL plans.(Required) I understand CBI is not able to accept Medicaid/Medical Assistance Are you using an EAP?(Required) Yes No In the event that we do not have any current openings with a provider in network with your insurance, are you open to self-pay services?(Required) Yes No Primary Insurance DetailsDoes the patient have commercial insurance? Yes, patient is covered under commerical insurance Yes, but patient is choosing to be a self pay client No, patient will be a self pay client Name of Insurance(Required) Insurance Member ID#(Required) Insurance Group#(Required) Policyholder Name(Required) First Last Policyholder Date of Birth(Required) MM slash DD slash YYYY Policyholder Relationship to Patient:(Required) Please upload a copy of the front and back of your insurance card so that our administrative team can assist verifying your insurance coverage and confirm your mental health benefits:(Required) Drop files here or Select files Max. file size: 50 MB. Does the patient have secondary commercial insurance?(Required) Yes No Secondary Insurance DetailsSecondary Insurance Name(Required) HiddenInsurance ID NumberInsurance ID Number(Required) HiddenInsurance Group NumberInsurance Group Number(Required) Policy Holder Name(Required) First Last Policy Holder Date of Birth(Required) Month Day Year Policy Holder Relationship to Patient(Required) Front of CardMax. file size: 50 MB.Back of CardMax. file size: 50 MB.Does the patient have tertiary commercial insurance?(Required) Yes No Tertiary InsuranceTertiary Insurance Name(Required) Insurance ID Number(Required) Insurance Group Number(Required) Policy Holder Name(Required) First Last Policy Holder Date of Birth(Required) Month Day Year Policy Holder Relationship to Patient(Required) Front of CardMax. file size: 50 MB.Back of CardMax. file size: 50 MB. EAPAuthorization Number(Required) Number of Sessions Covered(Required) Phone Number for EAP(Required) Services SoughtWhat type of services are you seeking?(Required) Psychiatry/Medication Management Self Pay Couples or Family Therapy with a Pre-licensed counselor ($60 per session) Self Pay Individual Therapy Services with a Pre-licensed counselor ($60 per session) *available for ages 6 and older Self Pay Individual Therapy Services with a Graduate-level intern ($25 per session) *available for ages 18 and older Self Pay Marathon Couples Therapy with a Gottman-certified CBI Therapist I was contacted from the waitlist Please provide the first and last name, date of birth, and relation to you of the additional people who will participate in couples or family counseling.(Required)Chief Complaint/Diagnosis for Seeking Treatment(Required) Has the patient ever had any alcohol or substance use, past or present?(Required) Yes No How often do you consume alcohol and/or use substances?(Required) Monthly or less 2-4 times a month 2-3 times per week 4 or more times per week No current use/Use was in the past Have you ever been evaluated for or prescribed psychiatric medications?(Required) Yes No Please list all of the medications you are currently taking (as well as the dosage) for psychiatric treatment:(Required)Are you currently taking/being prescribed any NON-psychiatric medications?(Required) Yes No Please list all of the current non-psychiatric medications you are taking/being prescribed, and who prescribes them:(Required)Do you currently have any other medical diagnoses (non-psychiatric) that we should be aware of?(Required)Have you ever been admitted to or received treatment from the following facilities? (Check all that apply)(Required) Hospital/ER Inpatient Facility Intensive Outpatient Program Partial Hospitalization Program Residential Treatment Center None, I have never received mental health treatment from one of these types of facilities. Please provide the name(s) of the facilities as well as the dates you received mental health treatment from them:(Required)Our psychiatric providers require formal psychological testing in order to treat the diagnosis of ADHD. Have you obtained formal psychological testing from a licensed psychologist to confirm this diagnosis?(Required) Yes, I have obtained testing and have a confirmed diagnosis of ADHD No, I have not had testing done to confirm my ADHD diagnosis I am not seeking psychiatric treatment for ADHD symptoms. Where/Who completed your psychological evaluation for ADHD?(Required) Please note that if you ARE seeking psychiatric/medication management services with CBI, our providers may require your medical records prior to scheduling. After submitting your information, if medical records would be required, our administrative team will email you a copy of a Release of Information form, which will need to be completed in its entirety so that we may request your records for you.(Required) I understand. SafetyHas the patient had any PAST thoughts of wanting to hurt themself or others?(Required) Yes No Has the patient ever attempted to hurt themself or others?(Required) Yes No Does the patient have any CURRENT thoughts of wanting to hurt themself or someone else?(Required) Yes No This form is not checked 24/7. If you are having thoughts of wanting to hurt yourself or someone else, please call your local mental health support hotline, such as 1-888-796-8226 (Resolve for Allegheny County, PA), the National Suicide Prevention Lifeline at 1-800-273-8255, call 911, or go to your nearest emergency room.(Required) I understand and will seek one of these or another service if needed SchedulingIf appointments are available, a member of our administrative team will call you. When is the best time for a member of our administrative team to call and reach you to coordinate scheduling?(Required) Are virtual appointments ok?(Required) Yes No If no, what is your preferred location? *IMPORTANT: Medication Management/Psychiatry is a VIRTUAL ONLY service at this time. Cranberry Township Mt Lebanon Monroeville Do you have a preference for a male or female provider? Female Male No preference I'd like to request a specific CBI clinician. Name of CBI clinician you are requesting:(Required) Is there anything else you think we should know?