Wellsprings Solutions Initial Intake Form

Please complete this form in its entirety. The information provided will help determine which of our counselors can best serve you based on your needs and their availability.

We DO NOT accept: UPMC 4 You, Amerihealth Caritas, Geisinger Health Plan, Highmark Wholecare, Health Partners Plans, Tricare and Quest Behavioral Health through Capital Blue Cross. 

PLEASE NOTE: The on-boarding process can take 3-10 business days, depending on the current volume of intakes. We do our best to process as quickly as possible, and we appreciate your patience. Any e-mail communication will come from intakeswellsprings@gmail.com
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Email *
Today's Date: *
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Full Name (First & Last) *
Age & Date of Birth *
Primary Phone Number: *
Is it okay to reply to you via email?                            Please check your email daily as this is the the easiest way to contact people.  *
Current Address (Include City, State, & Zip Code)
*We can only accept clients who reside in the state of Pennsylvania*
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Current Occupation: *
How did you hear about our practice? If someone recommended you, please provide the name of the person and context.
I am currently seeking counseling for:  *
If you are seeking counseling for someone other than yourself, please provide their information below. Include their first and last name, age and date of birth. Also include their email and phone #, if applicable. If you are seeking counseling for yourself simply put N/A.
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What brings you to counseling at this time? Please describe the presenting issue(s) in which you are seeking counseling for. Describe any pertinent details, like onset, symptoms, potential causes, how is it impacting your daily life, etc.
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What do you hope to accomplish or gain through your counseling experience? Include any goals you may have for yourself. *
Have you received prior counseling services? (If yes, please indicate when and how long prior treatment occurred) *
Do you drink alcohol or take drugs to intoxication?
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What time of day would you like to potentially schedule your appointments? (Check all that apply): *
Required

Just like with any other appointment with a medical professional, we have specific slots available throughout the day. We do our best to accommodate evening appointment requests, but evening availability is limited and dependent on counselor caseloads. We cannot guarantee that we will be able to accommodate requests for evening appointments. Is this acceptable to you?

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Would you prefer your appointments to be in-person or through Telehealth video?
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Would you prefer a faith based counselor?
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Fee for counseling may vary based on the clinician's education level and experience. Please refer to their counselor bio to see each clinician's current fee and insurance information.
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Required
Group therapy can be a more affordable option that individual therapy. Would any of the group therapy topics below interest you?
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If there was a particular counselor at our practice that you were hoping to see, please write their name below (optional)

You can read more about our counselors on our website.
Do you wish to use insurance to pay for counseling?  * Please note we do not take any medicaid or medicaid supplemental insurnace from the state.

We DO NOT accept: UPMC 4 You, Amerihealth Caritas, Geisinger Health Plan, Highmark Wholecare, Health Partners Plans, Tricare and Quest Behavioral Health through Capital Blue Cross. 

We can provide superbills for insurances that aren't covered and most of the time you can get some form of reimbursement, but you would have to check with your particular insurance. 

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What is your health insurance carrier?  Be very specific.
PLEASE SEE THE LIST ABOVE  OF INSURANCES THAT WE DO NOT TAKE.
Write the name that is on the front of the insurance card.
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You will need to confirm with your insurance provider your mental health benefits by calling them to find out if we are covered and what your out of pocket cost will be.

Do agree to call them IF we are able to accept you as a client?
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If you are completing this form and we are not accepting clients, would you like... *

PLEASE NOTE: The on-boarding process can take 7-10 business days, depending on the current volume of intakes. We do our best to process as quickly as possible, and we appreciate your patience. 
Any e-mail communication will come from intakeswellsprings@gmail.com

Please check your email daily!


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