Appointment Request Form

Appointment Request Form

In Him Christian Wellness
If you are at risk of hurting yourself or others, please call 911 or go to the nearest emergency room. For immediate mental health support you can also contact the Mental Health Crisis Care line at 988.

New clients who want to set up an appointment should complete this form and click the submit button. Our intake team will then reach out to you with the remaining forms and answer any questions you may have. All forms will be submitted securely to our Intake Coordinator for review and assignment to a clinician, who will reach out to you to schedule your initial appointment.

Your assigned clinician will go over the informed consent with you, as well as any other information you may have questions about. If you'd prefer to talk to our intake specialist via phone, you may call (717) 585-0627.
Client Name:*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Phone Number*
Please provide a phone number where we can contact you.
Can we TEXT you at this number?*

YesNo
Can we LEAVE VOICEMAILS at this number?*

YesNo
Clinicians at In Him Christian Wellness are only able to provide services (including telehealth) to clients located in Pennsylvania and Virginia at the time of services. Are you currently located in Pennsylvania or Virginia or able to travel to one of our locations?*

YesNoI need to talk to someone about this
Who is completing this form?

I am the client.I am NOT the client.
Name of Individual completing form

My relationship with the client is: self/parent/friend .

If the client is a child:
Parents/Legal Guardians are married/together
Parent/Legal Guardian is widowed
Parents/Legal Guardians are living separately or divorced
*Please Note: For clients who are 13 years or younger, we do ask the parents/guardians to attend a parent consultation with a clinician WITHOUT their child to go over expectations, goals, and pertinent information about treatment for their child. You will receive paperwork about this consultation if you are filling this out for a minor. If you have questions or concerns about this, feel free to reach out to our intake team.
Scheduling Information

*Our first priority is to assign clients to a clinician with whom we believe would be the best fit according to a client's wellness needs. Please note that we try to meet clients' preferences. However, due to availability, insurance limitations, and clinicians' scope of practice, or other limitations, it may not be possible to meet all preferences.*
Please select your preferred location - choose all that apply. (To see specific addresses, please go here: https://www.inhimchristianwellness.org/home.)*

Lemoyne, PACarlisle, PAShrewsbury, PAHalifax, PAHarrisonburg, VATelehealth
Type of Therapy Requested (Choose all that apply ):*

Individual TherapyCouples TherapyFamily TherapyChild Therapy and Play ExercisesIntegrated Service (see below)
We offer integrated services to treat the whole person. Please choose other services you may be interested in learning about (additional fees apply; locations and rates vary):

NutritionMovement and MindfulnessSpiritual DirectionLife CoachingFinancial Counseling
Clinician Preference

Best FitFemaleMale
Clinician Request
Enter one or more Therapist Name(s) if you have a preference.
Appointment Availability:*
Please indicate general days and times available.
Provide a brief description of concerns to be addressed in therapy:*
How did you hear about us:

FriendFamilyChurchHealth ProfessionalInternetOther
Payment Information
Insurance

A number of our therapists are in network with several insurance companies. Please contact your insurance company to determine if we are in-network (plans vary from person to person). Our billing team will also verify insurance eligibility once insurance information is provided.

Our current in-network plans are as follows:
- Aetna
- Capital Blue Cross
- Highmark Blue Cross
- Blue Shield of Pennsylvania
- Magellan Health Services
- Mazzitti and Sullivan EAP services
We are unable to accept Medicaid or Medicare plans. When requested, we can provide a receipt or superbill with the proper codes that you can submit to your insurace company for possible reimbursement of our fee.
If using insurance, please choose your insurance plan:
*If other, please contact an In Him employee to discuss
If using insurance, please provide your insurance ID:
*Our billing team will verify your insurance eligibility before scheduling
Self-Pay: Out of Pocket Payment

We can offer a reduced fee to those in need, based upon gross, annual household income. If you are not able to afford your hourly rate, we will refer you for a consultation with one of our financial counselors. They will assist you in determining an affordable amount or a payment plan.
Our ability to provide low-cost sessions is provided by community and church support through donations. If you or someone you know are interested in donating to this cause, please donate through our website at https://www.inhimchristianwellness.org/support, or mail a check to 635 N. 12th St, Suite 101, Lemoyne, PA 17043. Donations are tax deductible, with receipts available upon request.
Will you be using insurance or paying out-of-pocket?*

Insurance (go to next question)Out of Pocket (skip next two questions)Supplement (Church, family, friend)Employee Assistance ProgramUnsureOther
Consent for Telephone/Email Communication

Includes voice messages and texting
*If you choose to obtain services from IHCW, you may be asked to sign this again.*

Mobile Phone Communication. Please note that if we communicate via staff’s mobile phone, by voice or text, your phone number will be stored in the phone’s memory for a period of time, and, therefore, if staff’s mobile phone is lost or stolen, it is theoretically possible that your contact information might be accessed. Note that the mobile phone is password protected and may be protected by facial recognition or fingerprint.

Please be aware that mobile phone communication via voice or text may not be entirely secure. Conversations may be intercepted or recovered, jeopardizing complete confidentiality. While it is your choice as to how much you disclose in these modes of communication, it is recommended that you limit comments to minimal and non-identifiable information (i.e., scheduling and cancellation)

Email Communication. If you elect to communicate with your clinician by email, please be aware that email is not completely confidential. Please be aware that your clinician may access email communications via his or her password-protected mobile phone and/or laptop. All emails are retained in the logs of your and/or our internet service provider. While under normal circumstances no one looks at these logs, they are in theory, available to be read by the system administrator(s) of the internet service provider. It is theoretically possible that if the mobile phone or laptop is lost or stolen and the password is somehow circumvented, our email communications could be accessed, even if deleted.

All such emails will be deleted as soon as possible. Emails with content related to treatment will be added to your client records, but such emails are strongly discouraged. While it is your choice as to how much you disclose in this mode of communication, it is recommended that you limit comments to minimal and non identifiable information (i.e., scheduling and cancellation).
Signing below indicates my understanding that this form is not a therapeutic contract, therefore it does not commit me to services with In Him Christian Wellness or a specific clinician. I also understand my assigned clinician will go over their specific professional disclosure and the Informed Consent at our first appointment, which will serve as the therapeutic contract at that time.
Signature*

Clear
Should be Empty:

Appointment Request Form

Scheduling Information

Payment Information

Insurance

Consent for Telephone/Email Communication