Appointment Request - The Peacemaker Center

Appointment Request

CONFIDENTIAL

New clients who want to set up an appointment at The Peacemaker Center should complete our confidential Appointment Request form. It is submitted securely to our Intake Coordinator who will review it and assign a therapist who will reach out to you to schedule your initial appointment.

If this is an emergency, please dial 911.

If you are NOT the client please provide your name, phone number, and relationship to the client:

Client #1 Information

For Couples or more than 1 Child under age 14 - Fill in both Client #1 & Client #2 Information

Client Name *

First Name Middle Initial Last Name

Is Client Under Age 14? Enter Parent/Guardian Name

Client Age *

Client Birth Date *

Month Day Year

Client Gender: *

Male Female

Address *

Street Address
Street Address 2
City	State
Zip Code	Country

Client Phone Number *

This is a parent or guardian phone number

Client Email *

This is a parent or guardian email

When we contact Client #1:

Do not mention The Peacemaker Center name Do not contact by phone call Do not contact by text message Do not contact by email

Client #2 Information

For Couples or more than 1 Child under age 14 - Fill in both Client #1 & Client #2 Information

Client Name

First Name Middle Initial Last Name

Is Client Under Age 14? Enter Parent/Guardian Name

Client Age

Client Birth Date

Month Day Year

Client Gender:

Male Female

Address

Street Address
Street Address Line 2
City	State
Zip Code	Country

Client Phone Number

This is a parent or guardian phone number

Client Email

example@example.com

This is a parent or guardian email

When we contact Client #2:

Do not mention The Peacemaker Center name Do not contact by phone call Do not contact by text message Do not contact by email

Scheduling Information

Best Location *

Downingtown West Chester Kennett Square Audubon Coatesville Fort Washington

Therapist Preference: *

Male Female Best Fit

Therapist Request:

Enter Therapist Names if you have a preference

Appointment Availability: *

Please indicate days and times available

Brief Description of Concerns to be addressed in Therapy: *

Type of Therapy Requested: *

Individual Couples Family

We can offer faith-based therapy without judgment or pressure. Do you want your faith included in your therapy? *

Yes No Unsure

How did you hear about us? *

Friend Family Church Internet

Payment Information

Note: We do not take insurance and are not in network with insurance companies but our therapists will on request provide a receipt with the proper codes that can be submitted to your insurance company for out-of-network reimbursement of our fee. Our fee is based on a sliding scale with full pay on the scale set at $125/session. We can offer a reduced fee to those in need, based on our sliding scale. Enter details below.

Are there any financial concerns we should be aware of? *

No Yes

Details of your Financial Concerns: