Request a New Appointment

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If you are in crisis and are unable to reach your therapist, call the Crisis line at (808) 832-3100, call 911, or proceed to your nearest emergency room immediately.

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Client's Preferred Appointment Times*

	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday: Telehealth Only 1:30-4:30p
8a - 11a
11a-2p
2p-5p
5p-7p

Insurance Coverage*

	HMSA PPO/HMO/Fed	HMSA Quest	HMAA	UHA	Out of Pocket (Cash)	N/A
Primary
Secondary

Will the provider need to complete documentation for 3rd parties (i.e. letters, work leave, disability determination, job readiness, legal proceedings)?*

YesNo

Unfortunately, we are unable to provide documentation services related to job/work readiness, workmen's compensation, disability determination, or legal issues (i.e. to attorneys; custody) given our scope of practice.

If you are unsure, you may list your specific request/concern in the Comment section below so we can best assist you.

Otherwise, you may exit this form at this time.

Thank you for contacting us.

Location Preference*

OnlineIn-Person

Name of Person Completing This Form*

First NameLast Name

Contact Phone Number:*

Email*

example@example.com

Which of the following is preferred for leaving messages:*

PhoneTextEmail

Reason for Appointment*

Individual TherapyParent Support for Behavioral issues (Brief Therapy: 4-6 telehealth sessions)Testing: ADHD concerns and consultationTesting: LEARNING concerns and consultationGroups: Boy's Mission-Possible Crew (Social skills & resilience for Ages 6-15)Groups: Girl's Create & Connect Club (Social skills & resilience for Ages 8-15)EMDR (Eye Movement Desensitization and Reprocessing); Trauma/Anxiety - Adults only

Referred By:

Referred To:

Client Will Be:*

New or Returning Client?*

New Client (never been seen at MPG before)Returning (previous MPG client)

Client's Name*

Client's Date of Birth*

Client's Age*

Client's School (If a student)

Client's Grade (if a student)

For minors, please confirm parental status:*

Parents are TogetherParents NOT together: BOTH parents have LEGAL custody of the minor)Parents NOT together: ONE parent has LEGAL custody of the minor)

If parents are not together (there is a separation, divorce or custody agreement), we require consent from BOTH of the minor's parents or legal guardians PRIOR to scheduling an intake appointment. Each parent or legal guardian MUST complete and sign the electronic Policies & Consents. Upon receipt of this completed form, we will send electronic Policies & Consents to each parent using a secure link or Client Portal using the email addresses provided.

In the event that only one parent has SOLE LEGAL custody, we may require supporting court documentation.

1st Parent *

Parent 1 First NameParent 1 Last Name

1st Parent Email Address*

1st Parent Phone Number*

2nd Parent *

Parent 2 First NameParent 2 Last Name

2nd Parent Email Address*

example@example.com

2nd Parent Phone Number*

Has the client been referred for any of the following reasons:*

Behavioral issues in children and adolescents are often effectively treated with behavioral modification, an intervention implemented by parents. It does not replace individual therapy and sometimes both are needed. Are you interested in brief Parent Behavioral Management training (4-6 telehealth sessions)?

Yes, I am interested in Parent Training to help address behavioral challenges.No, I am not interested in Parent Training.

Please feel free to share any additional comments or questions here.

Optional: List specific days of the week and times available.

Email

example@example.com

As a courtesy, if the Mililani Psychology Group is unable to offer an appointment, we can forward this completed form to independent clinicians (not MPG employees) who work at our clinic with your permission. Please check the boxes indicating which, if any, clinician you would like us to forward this form:*

Carolyn Coldiron, LMHC (independent private practitioner) if MPG is unable to accept my case.Please do not send this completed form to any clinician who is not an MPG employee.Other

As a courtesy, if the Mililani Psychology Group is unable to offer an appointment, we can forward this completed form to independent clinicians (not MPG employees) who work at our clinic with your permission. Please check the boxes indicating which, if any, clinician you would like us to forward this form:*

Maile Kimura, LMFT, BCBA (independent private practitioner) if MPG is unable to accept my case.Please DO NOT forward my information to anyone outside of the Mililani Psychology Group.Other

Email

example@example.com

You will receive an EMAIL response within 14 business days. Please check for a response in your spam/junk folder too.

Thank You!