New Client Interest Form
Please fill out this form as best you can so we can ensure we are a good match.
First name
Last name
Email
Phone Number
Payment options
Select an option
BlueCross Blue Shield
Sanford Health Plan
Health Partners
Optum
Medica
United Healthcare
Self pay
What concerns have you seeking therapy (choose all that apply)
Depression
Anxiety
OCD
Grief/loss
Trauma
Relationship issues
Stress
ADHD
Other
Are you a first responder?
Yes
No, but my partner is
No
Send