Mindful One LLC | SimplePractice

Mindful One LLC Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Reason for care

What type of service are you seeking?

Psychotherapy Assessment

What is the reason for seeking this service?

Tell us a little bit about what brings you in to seek services. What have you been experiencing?

Limited to 600 characters

How long have you been experiencing these symptoms?

A few weeks A few months A few years Many years

Administrative

Referral source

Let us know how you were referred to us

Are you currently seeing another therapist?

Is this Court-Ordered?

Billing & Payment

Insurance card upload

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Home/Billing Address

Type the address associated with the insurance

Insurance

Insurance Member ID

Name of Primary Insurer

DOB of Primary Insurer

Relationship to the Client

Client Preferences

Preferred appointment times (Therapy Only)

Morning (10am-12pm) Afternoon (12pm-4pm) Evening (4pm-6pm) Anytime

Please choose what days work for you (Therapy Only)

Monday Tuesday Wednesday Thursday Friday

Please choose what type of appointment you prefer (Therapy Only)

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.