Request an Appointment v2 Name*Date of Birth Date Format: MM slash DD slash YYYY Email* Phone*Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What is the best way to contact you?* Phone (call) Email I'm seeking services for*MyselfMinorCouple's CounselingFor Couples OnlyName of Partner*Date of Birth Date Format: MM slash DD slash YYYY Phone*Email* Address if different from the above listed Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Minor ConsentMinor Consent* I understand if I am seeking services for a minor, proof of custody arrangement will need to be provided before clinical services can be rendered. This applies to those who have shared custody or other arrangements*Initials*Please share briefly the nature of your counseling need.Please share counselor preferences you have.Other CommentsAre you a member or regular attender of a local church? If so, what church do you attend? (we will not contact your church without permission)How did you learn about Wellspring? Internet Search Pastor Physician Friend Other Other referencesAre you in need of a sliding scale application?*YesNoWould you like more information on church financial assistance?*YesNoSliding Scale Consent SectionSliding Scale Consent* I understand all sliding scale applications and church financial assistance will need to be completed and processed before a scheduled intake appointment in order to determine a reduced session fee and or to apply church financial assistance to a client's account. Failure to complete the sliding scale application or church financial assistance before an intake appointment will warrant a client to pay the full session fee upon the intake appointment or to reschedule the intake appointment.*Initials* All requests for counseling via the Wellspring Counseling website will be processed within 48 hrs. excluding weekends.