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Cohan Counseling

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Intake Request Form

Get Started

Please fill out the intake form below to request an appointment. Appointments are at the discretion of the practice and may not be accepted at this time for various reasons including but not limited to, time of day needed, inactive insurance or custody challenges

Appointment Request

Appointment Request

Please note appointments are limited and at the discretion of the clinician

First and Last Name of client*

First and Last Name of parent/guardian (if minor under 18)

Who has custody of the child? (if minor)

Is there a current custody order? (if minor)

Was therapy recommended by someone? Who? *

Email*

Phone *

Address

Why are you seeking therapy?

Depression

Anxiety

Family conflict/challenges

Behavioral concerns

Other

Tell us about your current concerns and mental health challenges*

Insurance company and ID*

Who is the insurance plan through?

Birthday of client *

Month

Day

Year

Please attach any extra documents you would like to share (Psychiatric evals, custody agreements, court documentation, IEP/504 plans, etc.)

717-322-2818 ext.100

Chambersburg, PA, USA

Disclaimer: The information contained on this website s is for informational purposes only and should not be used as a substitute for the advice of a mental health professional. Reliance on this information is at your own risk.

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© 2035 by Cohan Counseling. Powered and secured by Wix

Custody Order Policy.docx

Custody Order Policy.docx

Code of Conduct.pdf

Code of Conduct.pdf

compliance policy.pdf

compliance policy.pdf

© 2035 by Cohan Counseling. Powered and secured by Wix

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