Appointment Request

Appointment Request - CONFIDENTIAL

The Peacemaker Center

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.
Person completing this form (If NOT the client) - Provide Name, Phone #, Relationship to client
Client #1 Information

Couples or 2 Children under age 14 fill in both Client #1 and 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
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

Couples or 2 Children under age 14 fill in both Client #1 and 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
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
Type of Session - Indicate all that apply *

Telehealth In-Person
Best Location - Indicate all that apply *

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
For Grant purposes indicate Race: *

Asian Black/African American Hispanic/Latino Multiracial White/Caucasian
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-$6,000,000.00
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/fifty-minute session. We can offer a reduced fee to those in need, based on our sliding scale.
Are there any financial concerns we should be aware of? *

No Yes - You will be asked to complete our Scholarship Approval form
Should be Empty: