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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 State ZIP Code
What is the best way to contact you?*
- Phone (call)
- Email
I'm seeking services for*
- Myself
- Minor
- Couple's Counseling
For Couples Only
Name 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 State ZIP Code
Minor Consent
Minor 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 Comments
Are 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 references
Are you in need of a sliding scale application?*
- Yes
- No
Would you like more information on church financial assistance?*
- Yes
- No
Sliding Scale Consent Section
Sliding 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.

Contact Us

2655 Yeager Rd, Ste 102
West Lafayette, Indiana

info@wellspringcenter.net

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