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Parent/Guardian Appointment Request Form at Wellness Within

Welcome to Wellness Within Collaborative. Please fill out this form if you are requesting an appointment for your child or for someone else for whom you are a guardian. We will contact you soon with next steps to find a therapist who best fits your child's needs. Thank you!

What is your first name?*

What is your last name?*

What is your email address?*

What is your phone number?*

How may we contact you?*

Phone

Text

Email

All of the Above

What is your child's first name?*

What is your child's last name?*

What is Your Child's Gender Identity*

What Are Your Child's Preferred Pronouns

Enter your child's Date of Birth in this format: YYYY-MM-DD

Please Select Your Insurance Provider*

Please Enter Your Child's Insurance Member ID:*

For Health New England - enter the last 2 digits of your Member ID:

Please enter the mental health provider number from the back of your insurance card:

Secondary Insurance Provider (if applicable)

Secondary Insurance Member ID

Street Address (This is used to verify insurance eligibility.)*

City*

State*

Zip Code*

Please select the primary reason you are seeking therapy for your child:*

Please describe in your own words your reason for seeking therapy for your child:*

Preferred Appt Time

Preferred Appointment Days

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Is there a specific therapist you'd like to request at our center?