Healthy Minds Consulting, LLC

Healthy Minds Consulting, 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 is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Individual Therapy (18 & Up) Individual Therapy Child Couples Therapy Family Therapy ADHD Assessment Consulting

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

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Referral source

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Billing & Payment

Payment method

How do you plan to pay?

Insurance details

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Client Preferences

Preferred appointment times ( This helps us to match you with the therapist that has similiar availability to you)

Morning Afternoon Evening Any Time

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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Preferred Therapist

Leilani Mason, LICSW ( Teens, Adults & Couples) Jennifer Little, LMFT ( Children, Adults & Couples) Emily Ponder, LMSW ( Children, Adults & Couples) Chania Mitchell, ALC ( Children & Adults) Anna Drazich ( Student Intern) Sliding Scale Kenita Bell ( Student Intern) Sliding Scale Whoever you feel is best fit for me Whoever has the soonest opening! I am ready!

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.