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Request for new patient Therapy appointment
I acknowledge that this form is for therapy (non-medication) appointment requests 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.
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I Agree
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Indicates required field
What insurance do you have?
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Anthem (BCBS, FEP, Other)
Tricare
Medicare
CareFirst
Other - I plan to self-pay
Do you have medicaid?
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Yes
No
Contact Name
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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.
Email
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Phone Number for Contact
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Please provide the best telephone number to reach you to schedule an appointment, if an appointment is available.
What are the best days/times to contact you?
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Contact is:
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Adult seeking services
Legal Guardian of a child seeking services
Healthcare Provider seeking referral
May we leave a voicemail at this number?
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Yes
No
Age of Client
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What is the age of the person for whom you are seeking services?
What is your primary concern?
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Anxiety/worry/stress/panic
Mood concerns (depression, bipolar, down mood)
Behavioral issues for my child/adolescent
Trauma/PTSD
Adjustment concerns
Life Stress
Eating Disorder/concerns
Autism Spectrum Services
ADHD or Learning Issues
Prenatal or Postnatal Issues
Infant/Toddler Parenting Concerns
Couples or Marital Therapy
Family Therapy
Parent Consultation
Psychological Assessment/Testing
Family or Relationship Issues
Other
Please indicate your main concern - we know your concerns may be complicated or that you may have more than one. However, this will give us an idea who might be a good fit for you or your child.
If you have a preferred provider, please list their name here:
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If your preferred provider is not available, are you interested in seeing another provider?
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yes
no
I am interested in:
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Video/Telehealth Sessions Only
In-Person Sessions Only
Either Video or In-Person
Who referred you to WellSpring? (if applicable)
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Thank you for your request! If an appointment may be available, we will contact you within 5 business days to discuss options. 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!
Submit
