Heart of Mind Therapy, PLLC

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Gender

Street Address/ City/ State/ Zip Code

Date of Birth

Name you prefer to go by (nickname).

Administrative

Inquiry reason

Please select all applicable options.

Inquiry about therapuetic approach, methodology, and/or specializations. Inquiry about rates and fees. Inquiry about therapist availability. Request a free Phone Consultation. I'm ready to schedule my first appointment!

Referral source

Provide the name of the source that referred you to Heart of Mind Therapy? (e.g. Google search, Psychiatrist, Friend, Family, ect.)

Billing & Payment

Payment method

How do you plan to pay?

I intend to pay Out-of-Pocket. I intend to make payment using Atnea Insurance through the third-party insurance claims platform Headway, which is affiliated with Heart of Mind Therapy. I intend to make payment using Atnea Insurance through the third-party insurance claims platform Headway, which is affiliated with Heart of Mind Therapy. Someone else will pay for me.

Atnea or United Healthcare Insurance details

Full Legal Name/ Address/ Email/ Phone Number/ Date of Birth/ Insure/ Member ID/ Group ID or Number/

Limited to 600 characters

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning (9am-11:59am) Afternoon (12pm-3:59pm) Evening (4pm-6pm)

Preferred clinician

Select a clinician from the list

Preferred modality

Do you prefer in-office or telehealth?

In-Office Telehealth Both

Are there any other specific details you would like the Therapist to be aware of?

For example: what you'd like to focus on, diagnosis, previous treatment, etc. (Type N/A if there is nothing further to add)

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.