Wellsprings Counseling Services

Wellsprings Counseling Services
Request for Services
Today's Date:
First Name (of person seeking services):
Only ONE person per form
Last Name (of person seeking services):
Date of Birth (of person seeking services):
Age (of person seeking services):
Gender (of person seeking services):
Gender (of person seeking services)
Address

Street Address

CityState / Province

Postal / Zip Code
Is the person seeking services younger than 18?
Parent/Guardian:
Name of adult with LEGAL custody
Custody Arrangement:
i.e guardianship, foster care, sole custody, joint custody, etc.
Documentation:
i.e. court order, parent plan, etc. Type N/A if none exists.
Contact Phone:
If person seeking services is 18 or over, we must contact them directly.
Email Address:
example@example.com
Method of payment for services rendered:
Primary Insurance Provider
For Medicaid insurances, specify whether straight Medicaid, Amerigroup, CareSource, or PeachState.
Primary Insurance Member ID #:
For Medicaid, this # will begin with 111 or 222.
Primary Provider Services Phone #:
Located on the back of your insurance card
Primary Policy Holder Name:
exactly as it appears on card
Primary Policy Holder Date of Birth:
Secondary Insurance Provider (if applicable):
Secondary Insurance Member ID # (if applicable):
For Medicaid, this # will begin with 111 or 222.
Secondary Provider Services Phone (if applicable):
located on the back of your insurance card
Secondary Policy Holder Name (if applicable):
Secondary Policy Holder DOB (if applicable):
Are you seeking counseling or psychological testing?
NOTE: We do not offer psychological testing.
Describe the reason you are seeking services.
Would you be willing to be seen in our Watkinsville location?
"yes" or "no" answer
Which office location do you prefer?
*Preferences considered based upon availability of therapists at each location.*
Are you a previous client of Wellsprings?
Who was the previous therapist?
When was the last time the person requesting services was seen?
Requested therapist, if any:
Would you like counseling from a Christian perspective?
Referred by:
Should be Empty:

Wellsprings Counseling Services

Request for Services