Healing Hearts | Empowering Minds

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Billing & Payment

Insurance details

Limited to 600 characters

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Preferred clinician

Select a clinician from the list

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Are there any specific qualities you are looking for in your therapist that will help you feel more at ease?

How often would you like to be seen?

(open to recommendations based on assessment and consult, weekly, biweekly, monthly etc.)

Do you have any barriers to accessing mental health services/treatment that we should know about?

Time of day you prefer to be seen?

(morning, afternoon, evening, i'm flexible)

Reason for care

Are you looking for a colloborative care model?

(consulting with other physicians, school staff, etc)

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.