Secure Contact Form

Thank you for reaching out

This is a secure inquiry form for Abdi Patten Therapy. Once we receive your form, we will reach out via email within two business days to discuss next steps.

First name

Last name

Email address

Phone number

Home Address

Date of Birth

I give Abdi Patten permission to contact me via phone or email: Email is reserved for scheduling and administrative purpose only (e.g., appointment coordination, paperwork, or billing questions). Please note that I do not provide clinical support or therapeutic services via phone or email. If you are experiencing a crisis, please contact emergency services or a crisis line in your area.

Yes No

Reason for Services:

Please briefly describe what you are seeking services for?

How did you find Abdi Patten? Were you referred by someone?

If referred, please provide a name and how you know them

Do you have Health Insurance? We are required by law to ask if you have insurance. Abdi Patten Therapy is a fee-for-service, private practice provider and does not currently participate in insurance plans.

Yes No

Are you eligible for Medicare Benefits? We are required by law to ask if you qualify for medicare. Abdi Patten Therapy is a fee-for-service, private practice and does not currently participate in filing with/for medicare.

Yes No

Verification of Information I acknowledge and grant permission to be contacted at the information listed about from Abdi Patten, PLLC. I agree that I have completed this form for myself or a minor that I am guardian of. By checking 'Yes', it denotes my signature and validity to the above form.

Yes No

Consent and Acknowledgment:
By signing this form, you acknowledge that the information provided is accurate to the best of your knowledge. You also consent to being contacted by Abdi to initiate services as outlined in this form.

Abdi Patten uses Hushmail as a confidential, HIPAA compliant email service. You will need to login to a secure portal to view and respond to any emails. This can easily connect to your present email address.

Your information will be encrypted.