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) I am requesting an appointment for: myself or a family member a patient, student, or client of mine Submit 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.