APPOINTMENT REQUEST

Our availability status changes quickly. As one person wraps up, we can offer you sessions.

How long would you like to remain on my notification list, if we're full? We will be in touch when space is available.

1 week

1 month

3 months

Indefinitely

I have set sessions times. Please let me your preferred times, and when you're NOT available. Please be specific.

Did someone refer you, or are you making the request yourself?

SERVICE REQUEST Please describe your primary concern(s):

Adult Social Anxiety/Relational Anxiety

Other Anxiety Concerns: General anxiety, OCD, health anxiety, or panic. (Please describe below)

Executive function concerns or attention concerns (Please describe below)

Personal Growth ("I'm just looking for a good therapist"). Please describe your needs below.

Specialized counseling for high performer/high responsibility. Please check box if you're a business owner, executive responsible for a team, or MD.

Kama was recommended to me for a very specific concern (Please describe below)

Please describe your concerns in more detail:

First Name

Middle Initial

Last Name

Gender

Date of Birth

Month

Day

Year

*Complete Street Address

City

State

Zip

Email (double check, please)

Cell Phone

May we call you at this number?

Yes

May we text you at this number?

Yes

PAYMENT INFORMATION

All patients are required to keep a credit card on file. Payments, co-payments, and co-insurance is automatically paid once your claim is processed. A receipt with paid invoice will be provided by secure email.

I agree to keep a credit card on file (encrypted/federal law) and have my card charged for services not covered by my insurance.

INSURANCE/PAYMENT PREFERENCE

BCBS ND or BCBS PPO

Please upload your insurance card below.

Sanford Health

Please upload your insurance card below.

Private Pay

UPLOAD INSURANCE CARD PICTURE HERE ** REQUIRED** If using insurance, please provide a front photo of insurance card

Add file

Please upload a file

NON-TRADITIONAL COMMUNICATION CONSENT:

We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail.

I consent to receive text and email notifications for my appointments, invoices, and receipts.

I consent to HIPAA-compliant texting, when necessary or appropriate.

By sending this, I consent to the use of digital forms.

By sending this form, I acknowledge this is an appointment request form only. Please allow 5 -7 days for a response. If you don't hear from us, chances are - our reply went to your junk mail/inbox. We respond to all requests.

Your information will be encrypted.