Request for Therapy Appt

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. *

I Agree

Contact Name *

Phone Number for Contact *

Contact is: *

Adult seeking services Legal Guardian of a child seeking services Healthcare Provider seeking referral

Age of Client *

If your preferred provider is not available, are you interested in seeing another provider? *

yes no

I am interested in: *

Video/Telehealth Sessions Only In-Person Sessions Only Either Video or In-Person

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!

Request for new patient Therapy appointment