Wellspring Counseling & Coaching New Client Inquiry

Welcome to Wellspring! We are thrilled that you have chosen us to support you on your journey. Our team is dedicated to providing compassionate care and helping you receive the assistance you need.

Please complete the following form to get started. Once you have completed the form, our administrative team will reach out with next steps to schedule your initial session. 

We accept most major commercial insurance plans, as well as Medicare and Ohio Medicaid. We are not able to accept out-of-state Medicaid plans.

If you are interested in therapy with Dr. Breuninger, please inquire here. 

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If you are completing this form for someone else, please enter your full name and your relationship to the client.
Client First and Last Name *
Date of Birth *
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Email Address *
Telephone Number *
Do you consent to being left voicemails by Wellspring Counseling & Coaching? *
Are you seeking telehealth or in person services?

Please note that due to licensing laws, telehealth services are only available to clients physically located in the state of Ohio at the time of the appointment. 
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What is your general availability?  *
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Do you have a therapist preference? 

Please list any requests for specific types of therapy, therapist gender, or any other preferences under "Other".
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What is bringing you to therapy at this time?  *
How did you find out about us?  *
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Please select your intended payment type. *
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