Appointment Request
DISCLAIMER: Please complete the following form to initiate services with Living Waters Counseling and Wellness Center. Filling out this form will guarantee an appointment request. Based off of your needs and availability we will place you with the most suitable clinician in the practice. Allow 1-2 business days for our staff to digitally place you with a clinician and scheduled digitally for an intake. Be sure to provide accurate times for availability so that our staff schedules you in proper timing. 

Once appointment is made the client will need to fill out paperwork prior to their session that will be sent via SimplePractice. If paperwork, insurance, and payment is not filled before the session then the clinician will have to cancel. 

If you would like to be contacted by phone please state that in the form, or for any other additional information you need to make us aware.

We are looking forward to providing quality care for you & your family.
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Legal First and Last Name *
Home Address *
Phone Number *
Email  *
Date of Birth *
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Insurance Type *
Required
Insurance Member ID and Group Number *
Reason for Visit
Appointment Request For *
Couples:  Spouse's Legal First & Last Name
Couples:  Spouse's Phone Number
Couples: Spouse's Email Address
Couples: Spouses Date of Birth 
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Desired Clinician  *
Child's Legal First and Last Name (If being seen)
Child's Date of Birth (If being seen)
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