New Client Request for Services
Thank you for your interest in becoming a new client at A Center for Mental Wellness. Please answer the following questions and someone from our intake department will contact you within 24 business hours to discuss scheduling an intake appointment.
Client Last Name
Client First Name, Middle Initial
Date of Birth
Social Security Number
Current Employer/Name of School & Current Grade
Who referred you to our group or how did you hear about our services?
Do you have any special needs or accomodations we should be aware of to better assist you?
Address Line 2
Copy of driver's license or state ID if available (parent or guardian if a minor)
Name of Primary Health Insurance Plan or "None"
Primary Policy Holder's Name or "None"
Primary Policy Holder's Date of Birth or "None"
Primary Insurance Plan Policy Number or "None"
Primary Insurance Plan Benefits Phone Number or "None"
Copy of Primary Insurance Card (Front and Back)
Name of Secondary Health Insurance Plan (If Applicable)
Secondary Policy Holder's Name
Secondary Policy Holder's Date of Birth
Secondary Insurance Plan Policy Number
Secondary Insurance Plan Benefits Phone Number
Copy of Secondary Insurance Card (Front and Back)
Name of Tertiary Health Insurance Plan (If Applicable)
Tertiary Policy Holder's Name
Tertiary Policy Holder's Date of Birth
Tertiary Insurance Plan Policy Number
Tertiary Insurance Plan Benefits Phone Number
Copy of Tertiary Insurance Card (Front and Back)
In your own words, why are you requesting our services?
Please Upload Any Additional Documentation Here.
Which of our services are you interested in at this time?
School-Based Counseling in Kent County
School-Based Counseling in New Castle County
Chrysalis in Kent - Substance Abuse Program through DSAMH
Chrysalis in New Castle - Substance Abuse Program authorized by DSCYF
Building Bridges in Kent/Sussex at ACFMW - MST authorized by DSCYF
Building Bridges in New Castle at ACFMW - MST authorized by DSCYF
Family Solutions in Kent at ACFMW - Outpatient authorized by DSCYF
Family Solutions in New Castle at ACFMW - Outpatient authorized by DSCYF
Patient/Referral Source Email Confirmation. Please provide us with the email address of the person who is completing this referral whether you are the patient or a referral source. The email address provided here will be sent a confirmation email with a time and date stamped copy of the information that you have provided us with as documentation for your records. Please put "self" if you are self-referring and this confirmation will only be sent to you directly.