New Client Website Form

Wellness Works Counseling, LLC

Phone: 724-282-0332

Thank you for your interest in services with Wellness Works Counseling. Please complete the following questions to help us match you to the right therapist:

1. Are you in the state of Pennsylvania in the United States of America?

Yes No

Therapists at Wellness Works Counseling are licensed in the state of Pennsylvania and the country of the United States of America. If you are physically located in a state outside of Pennsylvania in the United States of America, consider contacting counseling services in your area. There is current pending legislation that may open services in the future. This form will be updated when expanded services are possible.

2. What type of therapy are you interested in?

Individual

Couples

Family

4. Tell us about yourself:

Name: First

Last

Date of Birth:

Phone Number:

Email address

Confirm Email address

What brings you here:

Do you prefer:

In-person sessions Virtual/Remote Sessions No preference

What is your general availability?

Day Night Open availability Weekends Weekdays

5. Are you interested in using your insurance:

Yes

No- Self-pay (Self-pay rates are $200 for 60 minute sessions)

If you are using insurance, provide your insurance carrier name(s): Primary Insurance

Primary Insurance Member ID Number:

Primary Insurance Group Number

If you currently have a Secondary or Supplemental Insurance, please enter carrier name:

Secondary or Supplemental ID Number

Thank you for taking the time to complete this form. Select the Submit button below. You will receive an invitation to our online portal the next business day. If you want to reach us directly call 724-282-0332 or email at welcome@wellnessworks-counseling.com. Thank you.

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