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):
*
Male
Female
Gender (of person seeking services)
*
Please Select
Male
Female
Address
*
Street Address
City
State / Province
Postal / Zip Code
Is the person seeking services younger than 18?
*
Yes
No
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:
*
I plan to self-pay (do NOT choose, if you want to use insurance)
I will be billing insurance
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?
*
Counseling
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?
*
Franklin Springs
Watkinsville
No preference
*Preferences considered based upon availability of therapists at each location.*
Are you a previous client of Wellsprings?
*
Yes
No
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?
*
Yes
No
Referred by:
Submit
Should be Empty: