Before we can schedule your first appointment, we need some information.

You indicated that you would like to upload your insurance information at a later time.

Once you complete this form you will receive an email with a link to upload your information when you are ready. 

Please be aware that in order to finalize your appointment this information has to be submitted.

Please carefully read the Mindful Care Policies and then complete the form below.

I acknowledge that I have reviewed all of Mindful Care's treatment and billing policies linked above and agree to be seen under those policies.

Adult Patient Consent to Care (18 years of age or greater)

I hereby authorize Mindful Care by and through its licensed medical professionals to provide me with mental health care services that such professionals deem necessary for diagnosing and/or treating my mental health condition(s). I hereby understand and agree that my sessions with Mindful’s mental health professionals may involve in-depth questions of a sensitive and personal nature including but not limited to such topics as (my history of diagnosed and/or undiagnosed mental health disorders and that of my family members, eating disorders, sexual history and/or abuse, history of suicidal and other self-harm tendencies and events, legal history/ history of interactions with law enforcement authorities, and substance use). I acknowledge and agree that if I am uncomfortable with the treatment outlined or line of questioning engaged in during my Mindful care session that I shall immediately notify my Mindful provider of such, so an alternative treatment regime may be utilized for my benefit. I acknowledge and agree that no guarantees and/ or assurances of any kind have been given to me concerning the results of Mindful’s mental health services including but not limited to the prospective improvement and/or resolution of my present mental health condition. I acknowledge and agree that I have been given the opportunity to ask questions concerning my pursuit of care with Mindful, and that all my questions have been answered to my satisfaction and that I am electing to pursue care with Mindful entirely of my own volition. My signature below indicates that I have fully read and agree to the aforementioned terms.

Parent/ Legal Guardian Consent to Care for Minor Child