Let’s Get to Know You

We want to learn more about what’s bringing you to us. The following steps will help us better understand your experiences, goals, and care preferences. Our team will contact you shortly.

Disclaimer: While this website is encrypted, data security cannot be guaranteed. Communications through this site are not confidential, and there is no expectation that health data will be protected. Submitting this form does not create a provider-patient relationship. By providing your information, you consent to be contacted by M.I.N.D. Health and Wellness via email, phone, or SMS. Message frequency may vary; message and data rates may apply. By continuing on our website, you are deemed to have agreed to these terms and conditions. You can also view our privacy policy to learn more or contact us via our HIPAA compliant platform.

Patient's Legal Name

First

Last

Legal Sex

Birth Date

Address

Address Line 1

Address Line 2

City

State

Zip Code

Confirm Email

Choose wisely as this email will be connected with your online medical record log in.

Mobile Phone

Patient's Age

We currently only see ages 5-60.

Birth the currently

Check this box if you need to also enter another point of contact, which will help manage the patient’s medical records or assist in treatment decisions.

Add Contact

How do you prefer to pay for our services?

How will we meet?

In-Office

Insurance companies are adjusting their payment rates lower for virtual (telehealth) visits. Therefore, we are only accepting in-person appointments at this time. If you have questions about your coverage, contact your insurance provider. Click Here Learn More

Are you currently getting psychiatric treatment from someone else?

Please describe how we can help.

Are you currently taking any psychiatric mediations?

How did you hear about us?

This helps us know how to better help others.