Counseling Services Request Form
Thank you for your interest in services 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) 721-1752 or via our email address,  info@thoughtfulwellness.com. 

At this time, our wait for services could be greater than 3-6 months. We are unable to accept children under age 15 to our waitlist at this time. 
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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 couple's counseling only). 

We will gather all of your partner's contact and insurance information during scheduling. Please enter potential client information as yourself (the partner who will serve as our primary point of contact during the waitlist period of time).
What kind of therapy are you seeking? *
Date of Birth of potential client *
MM
/
DD
/
YYYY
Email address of potential client or legal guardian *
Phone number of potential client or legal guardian *
May we leave messages on this phone number? *
Mailing address of potential client or legal guardian *
Zip Code *
County *
Primary Insurance of potential client *
Required
Member ID
(if medical assistance - must be STATE ID)
 *
Does the potential client have a Secondary or Tertiary Insurance? If yes, please provide the Insurance company's name and the member ID. If no other insurances, please move to next question. 
If your insurance is through a parent or spouse, please provide their name and DOB
Is the potential client's insurance through an employer or through the state? *
What is your general availability preference? (online, in-person, time of day, day of week) Please indicate if availability preference is FIRM or FLEXIBLE.  *
Please summarize in a couple of sentences why you are seeking services. This is so 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.)  Please indicate if clinician preference is FIRM or FLEXIBLE.  *
Is there anything else you feel would be important for us to know?
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