Counseling Services Request Form
Thank you for your interest in our services here at Thoughtful Wellness, LLC! Please fill out the information below and we will contact you as soon as we have availability to add you as a new client. For any questions or concerns please contact us at (717) 721-1756 or via our email address,  info@thoughtfulwellness.com. 
Sign in to Google to save your progress. Learn more
First and last name of potential client *
First and last name of parent/guardian (if applicable)
First and last name of potential client's partner (if seeking joint couple's counseling only). 

We will gather all of partner's contact and insurance information after new availability is established. Please enter potential client information as yourself- the partner who will serve as our primary point of contact during the waitlist period of time. 
Date of Birth of potential client *
MM
/
DD
/
YYYY
Email address of client or legal guardian *
Phone number of potential client or legal guardian *
Mailing address of potential client or legal guardian *
Zip Code *
Primary Insurance of potential client *
Required
Member ID, if medical assistance, must be STATE ID.  *
Does the potential client have a Secondary or Tertiary Insurances? If yes, please write out the Insurance payer's name and the member ID. If no other insurances, please move to next question. 
Availability- online, in-person, time of day, day of week *
 Please summarize why you are seeking services so that we can pair you with a clinician best able to offer support.  *
Do you have a clinician preference? (Male, female, a specific clinician you've seen on our website, etc.) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Thoughtful Wellness, LLC. Report Abuse
Google Forms