Dr. Van Brunt
Contact and Info
Insurance and Payment Info
Request for new patient Psychiatry Consultation
I acknowledge that this form is for psychiatry (medication) appointment requests with Dr. Heather Henig ONLY. I understand that WellSpring tends to stay full and may not have openings available. Submitting this form does not guarantee an appointment. Under no circumstances should this form be used for emergency situations. If this is an emergency please call 911 immediately or visit the local emergency room.
Indicates required field
I understand that the Psychiatry Department accepts ONLY Anthem and Tricare Insurance plans, and does not accept Medicaid or Medicare. I will be using the following to pay for services:
Anthem (BCBS, FEP, Other)
Other - I plan to self-pay
Please enter the name of the person we should contact to schedule an appointment. This should be the name of the client or the name of the legal guardian.
Age of Client
What is the age of the person for whom you are seeking services?
*Please be aware that Dr. Henig specializes in child, adolescent, and young adult psychiatry, and may provide referrals for adults over 40.
Phone Number for Contact
Please provide the best telephone number to reach you to schedule an appointment, if an appointment is available.
Self (Adult seeking services)
Legal Guardian of a child seeking services
Healthcare Provider seeking referral
I understand that WellSpring will contact me by phone, and may leave a voicemail at the number provided:
Who referred you for Psychiatry? (if applicable)
Please briefly describe why you are seeking a psychiatric consultation:
Please provide a brief statement about why you are seeking services (e.g., symptoms, diagnoses, specific problems you want to address).
Thank you for your request! If an appointment may be available, the Psychiatry Department Administrative Assistant, Jacqueline Hale will call you to schedule within 5 business days. Please be aware that, while we try to respond to every request, due to the high volume of requests, we may not be able to respond in cases where no appointments are available. Thank you for your understanding!
WellSpring Child and Family Psychology, PC
615 Emancipation Highway, Suite 101
Fredericksburg, VA 22401
Phone: (540) 693-0096
Copyright 2014; All Rights Reserved