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Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Are you looking for services at our St. Paul or our Northfield location?

we may not have availability at your preferred location but will reach out and let you know.

Reason for care

What is the reason for seeking care?

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Anxiety Attentional difficulties Depression Grief Relationship issues Trauma Other

What type of mental health therapy are you looking for?

click all that apply

General talk therapy (narrative or psychodynamic) EMDR Cognitive Behavioral therapy I am open to therapy interventions as recommended

Any previous interventions or current supports?

In therapy now Had had previous therapy Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently This would be my first time in counseling

Administrative

Inquiry reason

Billing & Payment

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Insurance details

Please list both primary and secondary insurances if you have two policies. Is the insurance through an employer or will you be using insurance through a government program?

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Insurance card upload

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Client Preferences

Preferred appointment times

Morning Afternoon Evening

Preferred clinician

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Preferred modality

What would be helpful for the therapist or administrator to know?

For example: topics for therapy, any special accomodations or preferences.

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For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.