Online Request for Services

Emergency Assistance

If this is an emergency, call:

Crisis Line: 1-800-273-8255
911

The following form is to request therapy services with Spring Forth Counseling, LLC. If you are in immediate crisis situation please call 911 or the National Suicide Hotline 1-800-273-8255 . You may also go to the nearest hospital emergency room for assistance. Please note that our counseling services are only provided to clients residing in Tennessee. We may take up to 3 business days to get back to you.

Client Information

First name

Last name

DOB

Month/Day/Year

State of Residence

Where will you be physically located for therapy sessions.

Email address

Phone number

I am a previous client

What is your preferred method of contact?

Email Phone

Date and Time

What days work best for you? (Select all that apply)

Tuesday

Wednesday

Thursday

Saturday (EMDR Intensive Only)

Sunday (EMDR Intensive Only)

No preference any day works for me

What times work best for you? (Select all that apply)

Morning (9am-12pm)

Mid-day (12pm-1pm)

Afternoon (3pm-5pm)

Evenings (5pm-7pm)

No preference any time works for me

Are you interested in EMDR Intensive Therapy?

Yes No

About Your Appointment

Insurance/Payment Options Available Select all that may apply

Private Pay

Id like to pay out of pocket

Health Savings Plan

Insurance (out of network benefits)

Pay for services up front and request reimbursement from your insurance company

Centerstone Military Services Grant

12 Sessions approved through Centerstone military services.

Grant/Charity/Non Profit Program

Other

If other selected list here

Please list your insurance provider

If other please specify.

Have you ever been hospitalized for psychiatric purposes?

Please answer the follow up question below if you answered "yes" to this question.

If so, was this hospitalization voluntary or involuntary?

Voluntary Involuntary

Are you currently taking psychiatric medications?

Yes No

Have you had therapy previously

Yes

Dates and Duration?

Dates and Duration

What brings you to counseling? Please be as detailed as possible, as this will help the therapist determine what services you will require.

Why did you choose Spring Forth Counseling?

If other specify here.

Thank you for completing the appointment request form. After submitting your form, you will be contacted within 3 business days via phone or email. You will be contacted in the method requested on the form. **Please note that we can only service clients residing in Tennessee.

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