Appointment Request

Appointment Request Form

CONFIDENTIAL
Para completar este formulario en español, haga clic aqui.
Date*

MonthDayYear
DateHourMinutesAM/PM Option
If this is a Mental Health Emergency, please dial 988, or contact the Chester County Crisis Center, open 24/7, at 610-280-3270.

New clients setting up an appointment please complete this form and click the submit button at the end. Fields with a red asterisk are required. You will be asked to sign our consent and both forms will be submitted securely to our Client Services Team for review and assignment to a therapist who is the best fit determined by your needs and the availability of our therapists and interns. Our clinical staff sets their own appointments and also finalize the fee with you when they contact about scheduling.
Who is Completing this Form?
Choose an option below:*

I am assisting someone to request an appointment - Complete the rest of this sectionI am a client requesting an appointment - Complete the Scheduling Information Next
Name of Person Completing the Form

First NameLast Name
Relationship to Client #1:
Phone Number of Person Completing the Form
Email of Person Completing the Form
example@example.com
Scheduling Information
Type of Therapy Requested (Choose One)*

Individual TherapyCouple TherapyFamily TherapyGroup Therapy
For Group Therapy indicate the group or class you are interested in below. Go to our website at www.thepeacemakercenter.org and click on the services tab for more information about these therapy groups.

Anger Management Program - Vicki Shay, MA, LPC, CSAM - Ongoing program - Fee to be determined with VickiKnitting, Crocheting, and Mental Health Individual Therapy - Karen Snyder MS - Locations, days, times depends on availability of clients and therapist - Ongoing group - Fee $50/session
I agree to pay the group fee indicated above. INSURANCE: We are not in-network with insurance companies and are unable to take insurance. Upon request, our therapists will provide a receipt with proper codes that you can submit to your insurance company for possible out-of-network reimbursement, if you have any questions about out-of-network benefits, please contact your insurance directly.*

YesNo
Indicate Total Household Income Range*

$0.00-$20,999.99$21,000.00-$25,999.99$26,000.00-$30,999.99$31,000.00-$35,999.99$36,000.00-$40,999.99$41,000.00-$45,999.99$46,000.00-$50,999.99$51,000.00-$55,999.99$56,000.00-$60,999.99$61,000.00-$65,999.99$66,000.00-$70,999.99$71,000.00-$75,999.99$76,000.00-$80,999.99$81,000.00-$85,999.99$86,000.00-$90,999.99$91,000.00-$95,999.99$96,000.00-$100,999.99$101,000.00-$105,999.99$106,000.00-$110,999.99$111,000.00-$115,999.99$116,000.00-$120,999.99$121,000.00-$125,999.99$126,000.00-$130,999.99$131,000.00-$135,999.99$136,000.00-$140,999.99$141,000.00-$145,999.99$146,000.00-$151,999.99$152,000.00-$1,000,000.00
Indicate the Type of Session for Individuals, Couples, and Family Therapy

Telehealth - Available to PA & DE residentsIn-Person - Indicate best office locations below
Best Locations for In-Person Sessions

Audubon - 778 Sunnyside AvDowningtown - 368 W Uwchlan AvKennett Square - 227 Lafayette StreetFort Washington - 500 W Office Center Dr, #100Morgantown - 2779 Main StreetNew Holland - 107 South Hoover AvPaoli - 73 Plank AvWest Chester - 312 W Union St
Therapist Preference

Best FitFemaleMale
Therapist Request - Enter one or more therapist names if you have a preference
Appointment Availability - Indicate general days and times available
Brief Description of Concerns to be addressed in Therapy:*
We can offer faith-based therapy without judgment or pressure. Do you want your faith included in your therapy?

YesNoUnsure
How did you hear about us?

FriendFamilyChurchInternetOther
Payment Information

INSURANCE: We are not in-network with insurance companies and are unable to take insurance. Please check with your insurance company for possible reimbursement and your therapist can provide you with a “Super Bill” for you to submit.

FEE: Our fee for a 50-minute session is specific to the therapist you are working with. We offer a reduced rate through our internship program if you are eligible. A sliding scale is also available upon request. Fees will be discussed with your assigned therapist during your initial contact.

* For those with more than enough financial resources, your full rate payment supports access for others to help rebalance systemic inequity.
Are you able to pay the full fee of $165 for a 50-minute session?*

Yes, I can pay full fee of $165 for a 50-minute sessionNo, I am in need of a reduced fee - A final determination will be discussed with your therapist.
Indicate the number of people in your household
Indicate Total Household Income Range*

$0.00-$20,999.99$21,000.00-$25,999.99$26,000.00-$30,999.99$31,000.00-$35,999.99$36,000.00-$40,999.99$41,000.00-$45,999.99$46,000.00-$50,999.99$51,000.00-$55,999.99$56,000.00-$60,999.99$61,000.00-$65,999.99$66,000.00-$70,999.99$71,000.00-$75,999.99$76,000.00-$80,999.99$81,000.00-$85,999.99$86,000.00-$90,999.99$91,000.00-$95,999.99$96,000.00-$100,999.99$101,000.00-$105,999.99$106,000.00-$110,999.99$111,000.00-$115,999.99$116,000.00-$120,999.99$121,000.00-$125,999.99$126,000.00-$130,999.99$131,000.00-$135,999.99$136,000.00-$140,999.99$141,000.00-$145,999.99$146,000.00-$151,999.99$152,000.00-$1,000,000.00
Indicate Client #1 Employment Status

EmployedUnemployedFull-Time StudentPart-Time StudentRetiredDisabled
Enter circumstances of need for a reduced fee, i.e. loss of job or income, high debt, etc.
SPONSORSHIP: Sponsorship is provided by community and church support through donations with 100% of the funds raised used to pay for direct client care.
If you have a church, organization, or another individual sponsoring you, please list them below:
Sponsor Name
Sponsor Phone
Sponsor Email
# of Sponsored Sessions
If an individual, church, or organization has provided you with their approval form please upload it here:

Browse Files

Cancelof
Client #1 Information
Client #1 Name*

First NameMiddle InitialLast Name
Client #1 Address*

Street Address

Street Address 2

CityState

Zip Code
Client #1 Age*
Client #1 Birth Date*

MonthDayYear
Client #1 Gender:*

MaleFemale
Client #1 Phone Number*
Client #1 Email*
*Please note: Email correspondence is not considered to be a confidential medium of communication
For Grant purposes indicate Race for Client #1:*

AsianBlack/African AmericanHispanic/LatinoMultiracialWhite/CaucasianOther
When we contact Client #1:

Do not mention The Peacemaker Center nameDo not contact by phone callDo not contact by text messageDo not contact by email
Client #1 Emergency Contact
Client #1 Emergency Contact Name*

First NameLast Name
Client #1 Emergency Phone Number*
Emergency Contact Relationship to Client #1*
Client #2 Information
Client #2 Name

First NameMiddle InitialLast Name
Client #2 relationship to Client #1
Client #2 Address

Street Address

Street Address Line 2

CityState

Zip Code
Client #2 Age
Client #2 Birth Date

MonthDayYear
Client #2 Gender:

MaleFemale
Client #2 Phone Number
Contact #2 Email
example@example.com
For Grant purposes indicate Race for Client #2:

AsianBlack/African AmericanHispanic/LatinoMultiracialWhite/CaucasianOther
When we contact Client #2:

Do not mention The Peacemaker Center nameDo not contact by phone callDo not contact by text messageDo not contact by email
Client #2 Emergency Contact
Client #2 Emergency Contact Name*

First NameLast Name
Client #2 Emergency Contact Phone Number*
Emergency Contact Relationship to Client #2*
Client #3 Information
Client #3 Name

First NameLast Name
Client #3 relationship to Client #1
Client #3 Address

Street Address

Street Address Line 2

CityState

Zip Code
Client #3 Age
Client #3 Birth Date

MonthDayYear
Client #3 Gender:

MaleFemale
Client #3 Phone Number
Contact #3 Email
example@example.com
For Grant purposes indicate Race for Client #3:

AsianBlack/African AmericanHispanic/LatinoMultiracialWhite/CaucasianOther
When we contact Client #3:

Do not mention The Peacemaker Center nameDo not contact by phone callDo not contact by text messageDo not contact by email
Client #3 Emergency Contact
Client #3 Emergency Contact Name*

First NameLast Name
Client #3 Emergency Contact Phone Number*
Emergency Contact Relationship to Client #3*
Client #4 Information
Client #4 Name

First NameLast Name
Client #4 relationship to Client #1
Client #4 Address

Street Address

Street Address Line 2

CityState

Zip Code
Client #4 Age
Client #4 Birth Date

MonthDayYear
Client #4 Gender:

MaleFemale
Client #4 Phone Number
Contact #4 Email
example@example.com
For Grant purposes indicate Race for Client #4:

AsianBlack/African AmericanHispanic/LatinoMultiracialWhite/CaucasianOther
When we contact Client #4:

Do not mention The Peacemaker Center nameDo not contact by phone callDo not contact by text messageDo not contact by email
Client #4 Emergency Contact
Client #4 Emergency Contact Name*

First NameLast Name
Client #4 Emergency Contact Phone Number*
Emergency Contact Relationship to Client #4*
Should be Empty: