Barksdale Missions, LLC dba The Well: Family Support

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Date of Birth

For minors, list the guardian’s name, email, and phone number below. Please do not list guardian contact details as the minor’s above.

Administrative

Inquiry reason

How did you find us?

How will services be paid?

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Insurance Provider

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Client Preferences

Preferred appointment times

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Morning Afternoon Evening Weekend

Preferred clinician

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Preferred modality

Reason for care

How can we help?

Clients/guardians: Briefly describe concerns or questions. Referring professionals: Include referral information.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.