Contact Information & Communication Consent

NOTICE: Currently, our providers are full. If you want us to contact you when we're accepting new intakes, between now and January, please complete the form. Please note, we'll only contact you if we're accepting new intakes.

Telephone 701.478.7199

1. What's your appointment preference?

When would you like to schedule your appointment?

I prefer mornings.

I prefer afternoons.

I prefer the lunch hour.

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

Please describe your primary concern(s):

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 email/text, and call you at this number?

Yes

My preferred communication is:

Phone

Text

Provider Request:

Anxiety/Trauma Specialist:

Erin Hagen, LPCC

Complex Anxiety Specialist:

Kama Jensen, LPCC

Please check insurance/payment preference: (We are not enrolled to accept government-issued medicaid plans)

BCBS ND or BCBS PPO

BCBS MN

Sanford Health

Private Pay

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.

I consent to provide/allowing charges on my credit card for the balance due at the time of the appointment (self-pay clients only). If using insurance, I consent to charges for my co-payment, and co-insurance once my claim has been processed.

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

AVAILABILITY NOTICE: Due to the high volume of requests and COVID-related factors, we're only able to respond if we can accept you as a new patient. Currently, both providers are full. We'll update this form as the availability status changes. We anticipate we will reopen to intakes in January 2021. However, we encourage you to complete this form if you believe we're a good fit for you!

I have read the AVAILABILITY NOTICE.

Your information will be encrypted.