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  • Appointment Request Form

    Maryhurst Renewal
  • Welcome!

    We're so excited to begin our partnership with you! To ensure we have the information we need to best serve you, please take a few moments to fill out the form below. Once submitted, someone from our staff will make contact and schedule an intake for services.

     

    If you have any questions, please feel free to contact us any time at (502)438-9639. Thank you!

    (Note for providers: this form is used to communicate with Maryhurst's counseling service, Renewal; if you're hoping to make a referral to our Residential Program, please contact Maryhurst admissions at admissions@maryhurst.org)

  • Unfortunately, Maryhurst Renewal is not currently accepting new referrals for therapy or ABA services at this time. If you would like to submit a referral for one of our other services, please remove the therapy selection above. If there are questions or concerns, feel free to contact our referral team at 502-438-9639.

  • Need more information about how these services can help? Click here:

    https://www.maryhurst.org/maryhurst-renewal-counseling-and-wellbeing-services

     

  • Contact Information

  • Please fill in the blanks with any identity preferences you have for your therapist (we will do our best to pair you with a Renewal team member who meets these specifications based on staff availability)
    Therapist race or ethnicity:
    Therapist gender identity:
    Therapist language spoken (other than English):    

  • (Note, we will not text prior to initial appointment, nor will Private Health Information ever be transmitted via text.)

  • Contact Information

  • (Note, we will not text prior to initial appointment, nor will Private Health Information ever be transmitted via text.)

  • Please provide insurance information (if applicable)

    Renewal accepts Kentucky Medicaid through Managed Care Organizations - as well as a number of private insurance providers; if you or the person you're referring will not be opting to bill insurance for services, you can leave this field blank.

  • Reason for Referral

  • By clicking submit above, the information on this form will be transmitted securely to staff at Maryhurst Renewal using end-to-end encryption through JotForm in full HIPAA compliance. A member of the team will be in touch shortly. 

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