Information, Consent and Insurance Forms

Click here to download and print out the forms you will need for your first appointment.

Rights and Responsibilities

Welcome to Wellspring! We are committed to providing quality services designed to enhance, strengthen and support individuals, couples and families. We strive to offer an atmosphere of respect and dignity to all our clients. Our therapists are here to provide help for a wide range of issues.

You may contact the center at 501-265-0046 during regular office hours to set up an appointment. We do not provide emergency psychiatric care, intensive psychiatric treatment, or residential/inpatient treatment. If you need any of these services we suggest that you call 911, visit a local emergency room, or call a 24-hour crisis hotline, 501-686-9300.

As a client of Wellspring you have certain rights which include:

  • The right to be fully informed about your treatment/counseling and the right to withdraw from that treatment at any time
  • You have the right to refuse treatment and our center’s personnel will inform you of potential consequences of such refusal
  • The right to seek disclosure from your therapist about his/her qualifications and, if necessary, the right to request a referral to another therapist
  • The right to access client grievance procedures via a written complaint addressed to:

Arkansas Board of Examiners in Counseling
101 East Capitol, Suite 202
Little Rock, AR 72201

  • The right to review your records by making a request in writing. Should you desire to do this, a staff member or your therapist will give you information on how to make this request
  • The right to confidentiality (see below)

Confidentiality means that what you tell your therapist will be kept confidential and will not be revealed to others persons or agencies without your written permission, except when mandated by state and/or federal statutes, and as part of the professional practice of this center. Exceptions to confidentiality include: Medical emergency, threats of serious bodily harm to self or others, suspected child abuse or neglect, and suspected abuse of the elderly. All Wellspring therapists abide by the American Counseling Association Code of Ethics.

As a client of Wellspring your responsibilities include:

  • Arriving on time to your appointments.
  • Giving at least a 24-hour notice should you need to cancel your appointment, or in case of an emergency, as soon as is feasibly possible.
  • If an appointment is missed or cancelled with less than a 24 hour notice, you will be charged for that session at a reduced rate of $40.
  • Giving a two-week notification of your plans to terminate treatment
  • Participating fully in your treatment goals and outcomes, including completing all assignments given by your therapist
  • Prompt payment of fees on the day services are provided.