P.O Box 81037 | Pittsburgh, PA 15217 | info@isalyca.com | 412.369.4285 (Main) | 412.939.0246 (Fax)

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We would love to help you!

If you are interested in scheduling a therapy session, please complete this form so that we can begin quickly matching you to one of our therapists.  We will contact you back to setup your first appointment.

 

While the form is the best way for us to match you up to one of our therapists, we also welcome you to schedule with us at 412.369.4285.

Our phones are staffed Monday through Friday, from 9am to 5pm.

Thank you for your interest in ICA. 

Personal Data
EAP (Employee Assistance Program) Data

If you have EAP sessions that you intend to use, please complete these fields.  Otherwise, you may leave them blank

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Insurance Data

If you will be using insurance to cover your visit, please enter the needed information below.  If you are using an EAP, the insurance information will only be used after you have used all of your EAP sessions.

If you do not have insurance, or intend to self-pay, then you may leave these fields empty.

Referral Data

If you were referred specifically to one of our therapists, please let us know so we can comply with that referral.  Otherwise, you may skip this section

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Scheduling Data and Reason for Visit

Finally, please let us know any time & location preferences you have, and presenting problem information so that we can best identify how we can help you.

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Day & Time Preferred (Check all that apply)