JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Appointment Inquiry
Please complete the attached form to submit a request for a new or returning client appointment at Wellspring Life Solutions Inc. A member of our staff will contact you within two business days to discuss your request and discuss appointment options.
Sign in to Google
to save your progress.
Learn more
Client Name
(Please complete a separate form for each family member, if applicable)
Your answer
Date of Birth
Your answer
Parent or Legal Guardian Name
(if under the age of 18)
Your answer
Telephone Number
(If multiple family members are requesting an appointment, we must have a separate telephone number for each client over the age of 18)
Your answer
Email Address
(If multiple family members are requesting an appointment, we must have a separate email address for each client over the age of 18)
Your answer
Client's City & State
(We cannot offer services to anyone located outside of the state of GA)
Your answer
Please provide a brief description of your reason for seeking therapy.
(Example: anxiety, depression, relationship issues, etc.)
Your answer
Do you have any insurance benefits you would like to use for your appointments?
(
Please list your primary and secondary insurance plans, if applicable. Example: Anthem BCBS, Alliant, GA Medicaid/Caresource)
Your answer
Are you currently enrolled in Medicare or a Medicare Advantage plan for healthcare coverage?
Yes
No
Clear selection
Type of Therapy Requested
Individual Therapy
Family Therapy (one form must be submitted for each participant)
Couples Therapy (one form must be submitted for each participant)
Were you referred to us by anyone?
Your answer
Which office location is most convenient for you?
Gainesville, GA
Cleveland, GA
Blairsville, GA
Virtual Telehealth Only
Are you open to a virtual telehealth appointment if in-office appointments are currently unavailable?
Yes
No
Would you prefer to see a male or female therapist?
Male
Female
Either
Clear selection
What days and times are you typically available for appointments?
Your answer
Are you currently under the care of a psychiatrist?
(We will request a list of providers on your new client paperwork)
Yes
No
Clear selection
Are you currently taking any prescription medications?
(We will request a medication list on your new client paperwork)
Yes
No
Clear selection
Are you currently involved in any legal issues that your therapist should be aware of? If applicable, please provide a detailed description.
(Example: divorce, child custody, disability, etc.)
Your answer
Thank you for completing this form. We value the trust you are placing in Wellspring Life Solutions to help you along your therapeutic journey. We look forward to speaking with you very soon regarding your appointment request.
Do you have any additional questions or concerns you would like to discuss when speaking with our staff member about your appointment inquiry?
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Wellspring Life Solutions, Inc..
Does this form look suspicious?
Report
Forms
