New Patient Enrollment | Mindful Healing Counseling

Full Name

Date of Birth

Month

Day

Year

Are you completing this form for yourself or someone else?

Myself

My child

Someone else

What type of appointment are you interested in?

Virtual therapy

In-person therapy

Either option

What insurance does the client have?

Insurance Member ID

Name of the Insurance Policyholder

Phone Number

Email Address

Best way to contact you?

Call

Text

Email

General availability

Weekday mornings

Weekday afternoons

Weekday evenings

Flexible

After we receive this form, how would you prefer to complete your brief pre-intake screening?

5-minute phone screening

3-minute questionnaire sent by email

New Patient Enrollment Form