Request An Appointment

WELLS OF WHOLENESS, INC.®

Well-Come!
About Us
Services (Our Wells)
Programs
Fees & Insurance
Appointments
- Confidentiality
Well-Fund (Please Give)

Please complete the Appointment Request Form below and click "submit" at the bottom.

This form is for new or returning client(s) only.
Appointment Request Form

* Indicates required field

Contact Information

Name *

First

Last

E-mail *

Phone Number *

May we leave a message? *

Yes No

How were you referred? *

Internet Search Advertisment Current/Former Client Physician Psychiatrist Counselor/Therapist Pastor Church member Co-worker Friend Other

If other, please provide name of referral. *

Income / Insurance Information

Combined Annual Gross Household Income *

Less than $10,000 $10,001-$25,000 $25,001-$40,000 $70,001-$100,000 > $100,000 Prefer not to say

Will you being using Insurance? *

Yes No Maybe

If yes, name of insurance carrier *

Aetna Amerigroup Cigna Humana Medicaid Peach State TriCare United Healthcare ValueOptions WellCare Other N/A

Select Service, Day, and Time

Select service requested *

Individual Counseling / Psychotherapy Couple Counseling (Unmarried/Non-premarital) Pre-marital Counseling Marriage & Family Therapy Group Therapy Pet Pastors (Pet loss/illness) Coaching (Vocational/Career) Coaching (Clergy) Consulting (Vocational/Career) Consulting (Other) Daddy Thirst Program D.A.N.C.E. Your Way to a Healthy Marriage Program H.Y.D.R.A.T.E. - Spiritual Direction, Growth, & Development

(Day - 1st choice) *

Monday Tuesday Wednesday Thursday Friday Saturday No preference

(Day - 2nd choice) *

Monday Tuesday Wednesday Thursday Friday Saturday No preference

(Time - 1st choice) *

Between 7AM - 10AM Between 10:30AM - 12N Between 12:30PM - 2PM Between 2:30PM - 4PM Between 4:30PM - 6PM No preference

(Time - 2nd choice) *

Between 7AM - 10AM Between 10:30AM - 12N Between 12:30PM - 2PM Between 2:30PM - 4PM Between 4:30PM - 6PM No preference

For Couple/Marriage Counseling ONLY

For Premarital Counseling ONLY

Partner/Spouse's Name *

First

Last

Fiance'/fiancee' 's Name *

First

Last

Partner/Spouse's Email *

Partner/Spouse's Phone Number *

May we leave a message? *

Yes No

Fiance'/fiancee' 's Email *

Fiance'/Fiancee' 's Phone Number *

May we leave a message? *

Yes No

Has wedding date been scheduled? *

Yes No N/A

If yes, month, day, and year of scheduled wedding. *

Comment(s) Note: Please allow 24-48 hours for a response. *

Submit

Well-Come!
About Us
Services (Our Wells)
Programs
Fees & Insurance
Appointments
- Confidentiality
Well-Fund (Please Give)

This form is for new or returning client(s) only. Appointment Request Form

Contact Information

Income / Insurance Information

Select Service, Day, and Time

For Couple/Marriage Counseling ONLY

For Premarital Counseling ONLY

This form is for new or returning client(s) only.
Appointment Request Form