Waitlist Request Step 1 of 13 7% 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) 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 the age of 18 Name of legal guardian initiating care for minor patient:(Required) Names of all current legal guardians for the minor patient, their relationship to the patient, and their contact information (phone number or email address):(Required)How did you hear about Cognitive Behavior Institute?(Required) DisabilityAre you seeking disability paperwork from a CBI provider?(Required) Yes No 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) I understand Workers Compensation & Social SecurityIMPORTANT: Please note that CBI is unable to accept Workers Compensation. We are also unable to provide evaluations for 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 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) Highmark Highmark Medicare Advantage Blue Cross Blue Shield UPMC UPMC for Life Aetna Aetna Medicare United/Optum United Medicare Cigna Tricare First Health GEHA Medicare Medicare Railroad Back on Track Ceridian/LifeWorks ComPsych Commercial LifeSolutions OnTrak PA CHIP Uninsured/self-pay None of the Above/self-pay Are you using an EAP?(Required) Yes No Are you open to self-pay services?(Required) Yes No Primary Insurance DetailsPrimary 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 secondary 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 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 SoughtWhich waitlist would you like to be added to?(Required) Individual therapy Couples or Family Therapy Psychological Testing EMDR Parent-Child Interaction Therapy (PCIT) Other What other services are you seeking?(Required) Please provide the first and last name, date of birth, and relation to you of the additional people who will be in couples or family counseling.(Required)Reason for Seeking Treatment(Required) Has the patient ever had any alcohol or substance use, past or present?(Required) Yes No SafetyHas the patient had any PAST thoughts of wanting to hurt themself or others? Yes No Has the patient ever attempted to hurt themself or others? Yes No Does the patient have any CURRENT thoughts of wanting to hurt themself or someone else? 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 SchedulingWhen 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) Call Text Email Are virtual appointments ok?(Required) Yes No If no, what is your preferred location? Cranberry Township Mt Lebanon Monroeville Do you have a preference for a male or female provider? Female Male I would like to request a specific CBI clinician No preference Name of CBI clinician you'd like to be added to the waitlist for: Is there anything else you think we should know?
