Wise Mind Counseling, PLLC

Wise Mind Counseling, PLLC Send Message

Who would be receiving care?

My partner and me

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 are you hoping to work on in counseling?

This information helps us understand your needs and whether our services are a good fit. You can select all that apply. Please note: this form is not monitored 24/7. If you are in immediate crisis or concerned about your safety, call 988 or your local emergency number, or go to the nearest emergency room.

Anxiety Attentional/focus difficulties Depression Grief or loss Relationship issues Substance use concerns Trauma or PTSD Health Anxiety Couples Counseling Family Counseling Other

Client Preferences

Preferred clinician

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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.

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.