Positive Minds Therapy LCSW P.C. Send Message

Who would be receiving care?

Your info

Please enter the full legal name of the person who will be receiving services.
Please enter the date of birth of the person who will be receiving services.
Please select the state where the person receiving services currently resides.
Please provide the name of someone we can contact in case of an emergency. For couples, you may list one partner as the emergency contact for the other, or provide an outside contact.
Please provide the best phone number for your emergency contact.
Please indicate your relationship to this person.
Reason for care
Limited to 600 characters
This helps us send the correct intake forms and match you with the appropriate clinician.
Limited to 600 characters
Administrative
If you are seeking services for a minor or another adult, we must confirm legal authority to consent to treatment.
(e.g., parent, spouse, guardian, partner, self)
(e.g., doctor, school, friend, Google, Psychology Today, insurance, etc.)
This helps our office respond to your request more efficiently.
Billing & Payment
This helps us verify benefits and determine if a Good Faith Estimate is required.
Please enter the insurance company listed on your card. (If Self-Pay, type Self-Pay)
Please enter the member ID as it appears on the insurance card. (If self-pay, type N/A)
This is often listed on the insurance card and may be labeled “Group” or “Plan.”
If same, write your name again.
Client Preferences
Let us know how you would prefer to meet, if you have a preference.
Please list the days of the week and time ranges that generally work best for you.
Limited to 600 characters

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.