• Psychological Testing Information and Waiting List Request Form

    Please read/review each section and check the box under each section to acknowledge/confirm that you understand and agree. Once all sections are checked, you will then be directed to a link to submit your information.

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  • As a reminder, we are in network with UPMC and ONLY accept commercial, employer sponsored, or plans purchased through the Market Place. NO CHIP, KIDS, UPMC For You (Medicaid/Medical Assistance) or UPMC For Life (Medicare) plans.

  • Please complete this section if you are age 26 or younger and are covered/utilizing your parent's insurance for services.

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  • *Only if parents are separated/divorced and patient is age 18 or younger and both parents need to consent for services*

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    *Only if parents are separated/divorced and patient is age 18 or younger and both parents need to consent for services*

  • *If known, please check all that apply.

  • *Please check all that apply.

  • *Can select none or both.

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