Appointment Request

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.
Today's Date*

MonthDayYear
DateHourMinutesAM/PM Option
If this is an emergency, please dial 911, or contact the Chester County Crisis Center, open 24/7, at 610-280-3270.

New clients who want to set up an appointment should complete this form and click the submit button. You will be asked to sign our consent and both forms will be submitted securely to our Intake Coordinator 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 someone will contact you to set up the first appointment and finalize the fee with you.
Who is Completing this Form?
Who is completing this form?*

I am the client - Skip to the scheduling Information section.I am NOT the client - Enter the information in this section below.
Name of Person Completing the Form

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

IndividualCoupleFamilyGroup
Enter name of group and/or leader of group if known:
Type of Session - Indicate both to schedule as soon as possible*

TelehealthIn-Person
Best Location for In-Person Sessions - Indicate as many as possible to schedule as soon as possible

DowningtownWest ChesterKennett SquareAudubonKing of PrussiaDouglassvilleFort Washington
Therapist Preference - Indicate all to schedule as soon as possible*

Best FitFemaleMale
Therapist Request:
Enter One or More Therapist Names if you have a preference
Appointment Availability: Indicate times other than late afternoon and evening to schedule as soon as possible.*
Please 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?*

FriendFamilyChurchInternet
Client #1 Information
Client #1 Name*

First NameMiddle InitialLast Name
Client #1 Age*
Client #1 Birth Date*

MonthDayYear
Client #1 Gender:*

MaleFemale
For Grant purposes indicate Race for Client #1:*

AsianBlack/African AmericanHispanic/LatinoMultiracialWhite/Caucasian
Client #1 Phone Number*
Client #1 Email*
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 Address*

Street Address

Street Address 2

CityState

Zip Code
Client #2 Information
Client #2 Name

First NameMiddle InitialLast Name
Client #2 relationship to Client #1
Client #2 Age
Client #2 Birth Date

MonthDayYear
Client #2 Gender:

MaleFemale
For Grant purposes indicate Race for Client #2:

AsianBlack/African AmericanHispanic/LatinoMultiracialWhite/Caucasian
Client #2 Phone Number
Contact #2 Email
example@example.com
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
Is Address of Client #2 the same as Client #1?

YesNo - Enter address below
Client #2 Address

Street Address

Street Address Line 2

CityState

Zip Code
Client #3 Information
Client #3 Name

First NameLast Name
Client #3 relationship to Client #1
Client #3 Age
Client #3 Birth Date

MonthDayYear
Client #3 Gender:

MaleFemale
Client #3 Phone Number
Contact #3 Email
example@example.com
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
Is Address of Client #3 the same as Client #1?

YesNo - Enter address below
Client #3 Address

Street Address

Street Address Line 2

CityState

Zip Code
Client #4 Information
Client #4 Name

First NameLast Name
Client #4 relationship to Client #1
Client #4 Age
Client #4 Birth Date

MonthDayYear
Client #4 Gender:

MaleFemale
Client #4 Phone Number
Contact #4 Email
example@example.com
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
Is the Address of Client #4 same as Client #1?

YesNo - Enter address below
Client #4 Address

Street Address

Street Address Line 2

CityState

Zip Code
Payment/Scholarship Information

INSURANCE: We operate on a sliding scale and are unable to take insurance since we are not in network with insurance companies. On request our therapists will provide a receipt with proper codes that can be submitted to your insurance company for out-of-network reimbursement of our fee.

FEE/SCHOLARSHIPS: Session fees are negotiated by the assigned therapist considering the client situation and our sliding scale. Full pay on the scale is set at $150 per fifty-minute session. For those in need we can offer a reduced fee through our Scholarship Program which is offered on a first come, first served basis, and is limited to 12 sessions followed by re-evaluation. When available our master’s level interns provide quality counseling at a reduced rate.

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 https://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.
For Grant purposes 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-$1,000,000.00
Do you have financial concerns with paying full pay on our sliding scale?*

NO, I do not have concerns - press submit button belowYES, I have concerns paying full fee amount - complete the information below
Indicate the number of people in your household
Indicate Client #1 Employment Status

EmployedUnemployedFull-Time StudentPart-Time StudentRetiredDisabled
Enter circumstances of need for scholarship, i.e. loss of job or income, high debt, etc.
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:

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