724-609-5002
125 Emeryville Drive, Suite 230
Cranberry Twp, PA 16066
1910 Cochran Road, Manor Oak 2
Suite 325, Pittsburgh, PA 15220
201 Penn Center Blvd, Building 1
Suite 520, Monroeville, PA 15235
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Waitlist Request

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At this time our office offers daytime appointments only for new clients. We are not able to add new patients to our waitlist requesting evening (4pm and later) or weekend appointments as those are highly sought after and limited spots are currently designated for existing clients. Please acknowledge below that you have read and agree to be added to our waitlist for daytime appointments during the week:(Required)

Patient Information

Patient Name(Required)
Patient Date of Birth(Required)
If patient is under the age of 18, is there a custody agreement filed with the courts?(Required)

Disability

Are you seeking disability paperwork from a CBI provider?(Required)
IMPORTANT: We are unable to complete disability paperwork for new clients until they have been established with a psychiatric provider for at least 3 months.(Required)

Workers Compensation & Social Security

IMPORTANT: Please note that CBI is unable to accept Workers Compensation. We are also unable to provide evaluations for social security benefits.(Required)

Contact Information

Home Address(Required)

Insurance and Payment

Please select your insurance from the list. Please note that if your insurance is not listed, we are unfortunately not in network, but we do have self-pay options. *We are not in network with any Medicaid/Medical Assistance products.(Required)
Are you using an EAP?(Required)
Are you open to self-pay services?(Required)

Primary Insurance Details

Hidden
Hidden
Policy Holder Name(Required)
Policy Holder Date of Birth(Required)
Max. file size: 50 MB.
Max. file size: 50 MB.
Does the patient have secondary insurance?(Required)

Secondary Insurance Details

Hidden
Hidden
Policy Holder Name(Required)
Policy Holder Date of Birth(Required)
Max. file size: 50 MB.
Max. file size: 50 MB.
Does the patient have tertiary insurance?(Required)

Tertiary Insurance

Policy Holder Name(Required)
Policy Holder Date of Birth(Required)
Max. file size: 50 MB.
Max. file size: 50 MB.

EAP

Services Sought

Which waitlist would you like to be added to?(Required)
Has the patient ever had any alcohol or substance use, past or present?(Required)

Safety

Has the patient had any PAST thoughts of wanting to hurt themself or others?
Has the patient ever attempted to hurt themself or others?
Does the patient have any CURRENT thoughts of wanting to hurt themself or someone else?
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)

Scheduling

When an opening becomes available, a member of our administrative team will reach out to you to schedule. What is the best way for a member of our administrative team to contact you?(Required)
Are virtual appointments ok?(Required)
If no, what is your preferred location?
Do you have a preference for a male or female provider?

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