Mind and Body Therapeutic Connections, PLLC

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

Sex at birth

For insurance verification

State

Select the state you live in

Administrative

Referral source

How did you find out about us?

Billing & Payment

Insurance details (If not using insurance, enter N/A to continue)

Insurance Carrier; Subscriber ID; Name of subscriber; Subscriber's home address; Subscriber's date of birth

Limited to 600 characters

Client Preferences

Preferred appointment times

Days/Times (example: M, W, Fri 8am-12pm)

Limited to 600 characters

Preferred modality

How do you prefer to be contacted?

Phone call Secure messaging through our client portal, Simple Practice (best for sensitive information) Text (we are only able to utilize this for very basic information since it is not HIPPA compliant) Email (we are only able to utilize this for very basic information since it is not HIPPA compliant)

Is there anything else you would like us to know to ensure optimal service for you?

For example: preferences about providers we will match you with, things that are impotant to you when matching you up, what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

If you are seeking care for a child (under 12 years old), couples therapy, or family therapy, would you like to be scheduled for a 20 minute, clinical consultation?

Yes No

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.