Wellsprings Counseling Services
Request for Services
Today's Date
*
/
Month
/
Day
Year
Current Time:
*
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):
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Male
Female
Address
*
Street Address
City
State / Province
Postal / Zip Code
Is the person seeking services younger than 18?
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Yes
No
Parent/Guardian:
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Name of adult with LEGAL custody
Custody Arrangement:
*
i.e guardianship, foster care, sole custody, joint custody, etc.
Documentation:
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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:
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example@example.com
How will you be paying for any services you receive?
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I plan to self-pay (do NOT choose, if you want to use insurance)
I will be billing insurance
Primary Insurance Company
*
For Medicaid insurances, specify whether straight Medicaid, Amerigroup, CareSource, or PeachState.
Primary Member ID #:
*
For Medicaid, this # will begin with 111 or 222.
Primary Provider Services Phone:
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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 Company:
if applicable
Secondary Member ID #:
For Medicaid, this # will begin with 111 or 222.
Secondary Provider Services Phone:
located on the back of your insurance card
Secondary Policy Holder Name:
Secondary Policy Holder DOB:
Are you seeking counseling or psychological testing?
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Counseling
Testing
Describe the reason you are seeking services.
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Would you be willing to be seen in our Watkinsville location?
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"yes" or "no" answer
Are you a previous client of Wellsprings?
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Yes
No
Who was the previous therapist?
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When was the last time the person requesting services was seen?
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Requested therapist, if any:
Would you like counseling from a Christian perspective?
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Yes
No
Referred by:
Submit
Should be Empty: