Appointment Request Form
CONFIDENTIAL
To complete this form in Spanish, click at the top right corner of the form and choose Spanish.
Para completar este formulario en español, haga clic en la esquina superior derecha del formulario y elija español.
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?
Scheduling Information
Payment Information
FEE: Our fee is $150 per fifty-minute session. Sliding Scale available upon request.
INSURANCE: We are not in-network with insurance companies and are unable to take insurance. On request, our therapists will provide a receipt with proper codes that you can submit to your insurance company for out-of-network reimbursement of our fee.
SPONSORSHIP/DONATIONS: 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 or someone you know are interested in donating to our Scholarship Fund please donate through our website at www.thepeacemakercenter.org or mail a check to 368 W Uwchlan Ave, Downingtown PA 19335 or contact us at 610-269-2661. Donations are tax deductible with receipts available upon request.
If you have a church, organization, or another individual sponsoring you, please list them below: Sponsor Name Sponsor PhoneSponsor Email # of Sponsored Sessions
Client #1 Information
Client #1 Emergency Contact
Client #2 Information
Client #2 Emergency Contact
Client #3 Information
Client #3 Emergency Contact
Client #4 Information
Client #4 Emergency Contact