Request for Services

We’re truly honored you are considering reaching out. If you feel ready, we invite you to complete and submit this form. Sharing whatever information you’re comfortable with will help us thoughtfully connect you with a therapist who can best support your needs.

Please know that while we have several caring therapists available, not all are able to accept every insurance or specialize in every area. We will do everything we can to find the right fit for you, but there may be some limitations based on availability or coverage.  If we believe we are a good fit for your needs, we will offer an intake appointment to get to know you and your goals more fully with one of our intake specialists.  After an in-depth discussion of your needs and desires, you will be matched with your on-going therapist.  We hope to have you connected and seen by our intake specialist within 5-7 days of your inquiry.   

We also want to be transparent that, because we are mandated reporters, any information shared here is not yet protected by client-therapist privilege, as a formal therapeutic relationship has not been established.

Evening appointments are in high demand and may not always be immediately available for on going therapy even if you are offered an evening appointment for your intake. 

We are here to support you and would be honored to walk alongside you as you take this important step.

*A note regarding insurances:  While we make every effort to verify insurances it is ultimately the client's responsibility to know your insurance benefits and deductible.  Please take the time to contact your insurance to make sure Matters of the Heart Counseling is in network.  

Last Name *

First Name *

Email *

Phone *

Can we leave a message *

Yes

Full name of Potential Client if Different than you

Date Of Birth of Potential Client *

Provide a brief explanation for the reason for services (Please remember we are mandated reporters) *

What is the Name of your insurance Company (we are able to accept most Highmark, Capital Blue, Quest, Aetna, Luminaire, UPMC, Perform Care, Geisinger.) We are NOT CHIP or MEDICARE Providers. Also some insurances have similar names or their mental health benefits are billed through a carve out payer. An example is SOME Highmark insurances carve out their mental health to Optum. We are NOT in-network with Optum. Independence Blue Cross may carve out mental health to Quest, we ARE in network with Quest. Please contact your insurance to make sure you are covered. If this will be self pay please indicate so. *

Subscriber Name, Date of Birth, Member ID of potential client. (We will use this to verify your insurance)

Are you interested in learning more about integrating Neurofeedback into your therapy? *

Yes

Maybe

Are you 18 or older and interested in participating in a research study which looks at the impact of utilizing Neurofeedback in reducing symptoms of anxiety? *

Yes

Maybe

I am open to seeing an intern at a reduced rate of $55 a session * *

Yes

Location Preference: *

Salunga/Landisville

Elizabethtown

Either

Please check all availability options you have for an appointment to make scheduling easier. Please note, appointments after 3pm are often unavailable.

How did you hear about us? *

If this request is for someone under the age of 14 we are required to have custody information on file if parents are not living together. Unless there is a court order, both parents have a legal right to be involved in the child's therapy. Are there any custody concerns we need to be aware of? *

Yes

Messaging Consent

By providing your phone number, you agree to receive text messages from Matters of the Heart Counseling . Message and data rates may apply. Message frequency varies. Reply STOP to opt out.