Wellsprings Psychological Resources
Online Referral Form for New Clients
Date of Referral *
Your answer
Client Name *
Your answer
Date of Birth *
Your answer
Gender *
Address of Client *
Street, City, State, and Zip Code.
Your answer
Parent/Guardian Name *
Your answer
Telephone Number *
Your answer
Referred By: *
Describe the reason you are seeking services: *
(Please limit response to 100 words or less.)
Your answer
Select the services you are requesting: *
Do you desire Christian counseling?
This may include prayer, scripture, Christian literature, etc.
If you are seeking a psychological evaluation, please answer the following: *
What information do you need from the evaluation? What are your expectations? Has an evaluation been completed before? When was it completed and by whom? Is there an IEP from the school system?
Your answer
Primary Insurance Company: *
Your answer
Name of Policy Holder *
If person insured is different than client, please list them here.
Your answer
Date of Birth of Policy Holder *
Your answer
Relationship of Client to Policy Holder:
Your answer
Insurance Identification #: *
Your answer
Phone number for insurance company's provider services or mental health services:
(This number is typically found on the back of the card. The number for Amerigroup, Wellcare of Georiga, and Medicaid is not required.)
Your answer
Requested Wellsprings Therapist:
If you have no preference, write NONE.
Your answer
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