Downloadable Forms
All client forms listed below are in Adobe PDF format and will open in a new browser window when you click on the hyperlink.
The free Adobe Acrobat Reader is available for download at www.adobe.com.
Counseling Services
- Application for Financial Assistance
- Client Mental Health Insurance Questionnaire
- Client Registration Form
- Consent for the Release of Information or Records
- Informed Consent
- Personal Data Inventory
- Renewal Application for Financial Assistance
- Third Party Guarantee of Payment Form
Please print and complete the appropriate forms according to your counselor's instructions and bring them with you to your counseling session or fax them in advance to Wellspring at 636.449.1268.
Conciliation Services
- Client Information Form
- Client Information Short Form
- Conciliation Services Agreement
- Consent for Release of Information or Records
- Filing Fee Agreement
- Non-Party Confidentiality Agreement
Please print and complete the appropriate forms as directed by the conciliation administrator. Please return requested forms by fax in advance to Wellspring at 636.449.1268.
Wellspring does not currently file insurance claims for clients. However, we are happy to assist you by providing the needed information for requesting pre-certification and/or the documentation needed to file claims for yourself. We have provided the following suggested questions to assist you when contacting your insurance company.
Questions Related to Insurance Benefits
For your convenience, our full-color brochure may be downloaded and printed for your reference.
Healing Hearts • Restoring Relationships • Liberating Lives