Schedule a Therapy Appointment

Your Name*(Required)

First Last

Your Email*(Required)

Brief reason for coming in: (We want to be sure we schedule you with the correct therapist)

Brief reason for coming in: (We want to be sure we schedule you with the correct therapist)

Which Office Location(s) Are You Interested In:

Society Hill

Fishtown

Lafayette Hill

Media

Willow Grove

Broomall

Telehealth/Video/Remote

Are you willing to consider telehealth/video/remote appointments? (Oftentimes, it can be easier to find a therapist who is a great fit for you by including telehealth appointments)

Are you willing to consider telehealth/video/remote appointments? (Oftentimes, it can be easier to find a therapist who is a great fit for you by including telehealth appointments)

Yes

Availability: (When would you be available for appointments? )

Availability: (When would you be available for appointments? )

Are you looking for anything in particular in your therapist (approach, gender, identity, age, etc)?

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Are you looking for anything in particular in your therapist (approach, gender, identity, age, etc)?

Client Name:

Client Name: (as it appears on the insurance card, if applicable)

Client Date of Birth:

MM slash DD slash YYYY

Insurance Type

Member ID #:

Member ID #: (if you are not the policyholder, please also provide the name and DOB of the policy holder)

Phone Number: (Please let us know if you prefer we not leave voice messages)

Phone Number: (Please let us know if you prefer we not leave voice messages)

What is the best times for us to call you at the above number to schedule/confirm your appointment?

Home Address:

Street Address City State / Province / Region ZIP / Postal Code

How did you hear about Equilibria?

Special Population

Emergency Responders

Children/Adolescents

Couples

Addiction Recovery

Eating Disorders

Grief

Please check if you would like to be added to our new and updated email list:

Yes

Equilibria Mental Health Services has merged with Equilibria Psychological and Consultation services. Equilibria has been proudly serving the community for over 15 years.
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