Enrollment Form

Provider Selection Form

Thank you for participating in the HopeForWellness Counseling Referral Program. Please complete this form to select your providers.
Full Name*

First NameMiddle NameLast Name
Phone Number*
This is my:
E-mail*
example@example.com
1. Primary Provider Choice: Please select a provider from the drop-down menu:*
Method of Service for Primary Provider (how you want to be seen): Please select your preferred service method for your primary choice:*
Note: Providers located outside of Evansville are only available via Telehealth.
2. Secondary Provider Choice: Please select a provider from the drop-down menu:*
Method of Service for Secondary Provider (how you want to be seen): Please select your preferred service method for your secondary choice:*
Note: Providers located outside of Evansville are only available via Telehealth.
3. Session Type: Which session type did you select on your enrollment form?*
Note: Providers located outside of Evansville are only available via Telehealth.
Please Note: We are committed to matching you with your preferred provider; however, availability is not guaranteed. Rest assured that all of our providers are highly qualified, compassionate, and experienced in mental health care. Please carefully consider your choices before submitting this form, as once a provider is assigned, changes cannot be made. We appreciate your understanding and encourage you to reach out if you have any questions before making your selection.

For questions or assistance, please contact the HopeForWellness team at hello@HopeForWellness.org or visit us online at HopeForWellness.org
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Provider Selection Form