New Client Request Form

I am Completing this Request for:

Myself Someone Else

If completing for someone else:

Your Name

Relationship to Client

Your Phone Number

Your Email

I am interested in:

Individual Therapy Registering for a Support Group or Course Both

I am interested in:

Well Mom: Postpartum Wellness Planning Group

This group is intended for pregnant persons and their partners and focused on planning for parental mental health in the fourth trimester.

New Mom Support Group

This support group is intended for women who have had a child within the past year.

Working Moms Support Group

This support group is intended for women who are navigating working and mothering.

Client Information

Client First Name

Client Last Name

Email address

Phone number

Client Date of Birth

Client Address

City

State

Do you plan to use insurance?

Yes, I plan to use insurance. No, I plan to self-pay.

Name of Insurance Plan

(BCBS, Cigna, Aetna, etc)

Please note your availability special request:

Please note if you prefer in-person or telehealth sessions.

In-person only Telehealth only No preference

Referral Source

How did you find us?

Reason for Seeking Therapy

Tell us breifly how we can help.

Communication Preferences By submitting this form, you acknowledge that Mind Made Well Counseling may contact you by phone, email, or text message regarding your inquiry, therapist availability, scheduling, and next steps. This may include follow-up communication if we do not hear back from you. We respect your privacy and communication preferences. If you prefer not to be contacted through a particular method, please select the applicable option(s) below. You may update your communication preferences or opt out of future communications at any time by contacting our office. Please note that standard email and text messaging may not be fully secure. We limit these communications to administrative and scheduling matters.

Do not contact me by phone.

Do not contact me by email.

Do not contact me by text message.

Your information will be encrypted.