Internal Schedule Now / Patient Registration Part 2

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

  • Are you a new patient?*
  • Has it been more than 4 months since your last appointment?*

  • As a returning patient, please email support@mindful.care to schedule an appointment. 

  • Format: (000) 000-0000.
  • State*
  • Preferred Appointment Date:*
     - -
  • Gender
  • Gender*
  • What are your pronouns?*
  • Date of Birth*
     - -
  • Are you using Insurance for this visit?*

  • Insurance Information

  • Insurance Provider?*

  • Before we can schedule your appointment, we will need a photo of the insurance card you would like to use.

    You can either upload those now or at a later time. 

  • Would you like to:*
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  • Payment 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.

  • Do you have a different mailing address?*
  • Format: (000) 000-0000.
  • Do you have a Primary Care Physician?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient Health Information

  • Are you seeking help with us to avoid an ER visit for your mental health needs?*
  • Are your symptoms directly related to the COVID-19 pandemic?*
  • Have you seen a Psychiatrist, Psychologist, or Therapist in the past?*
  • If So When?
     - -
  • Past Psychiatric History - Check All That Apply*
  • Are you currently taking any psychiatric medications?*
  • Do you have any drug/medication allergies?*
  • Are you currently using any of the following substances? (Check all that apply).*
  • Are You Currently taking any of the following medications?*
  • Family History - Check All That Apply*
  • Medical History - Check All That Apply*
  • Are you taking any other medications?*
  • What services are you interested in exploring? Check all that apply.*

  • 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.

  • Are you 18 years of age or older?*

  • 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.

  • Today's Date*
     - -

  • Parent/ Legal Guardian Consent to Care for Minor Child

  • I, *, the parent or legal guardian of * born     Pick a Date*  , do hereby give my consent as of   Pick a Date*     to the provision of any medical care as determined by a physician or other licensed medical provider of Mindful to be necessary for the welfare of the child while said child is under the care of Mindful Care and I am not reasonably available in person, by telephone or other means of electronic communication to give my consent and/or participate in the child’s immediate care. In the event I am not reasonably available to give my aforementioned consent, to accompany    *   and/or participate in the child’s care, I hereby authorize   *    to serve in my stead and make the following determinations that legally would be afforded to me as the parent/legal guardian of the child;

  • (check all that apply)

  • This authorization is effective from   Pick a Date*   to   Pick a Date*   

  • Should be Empty: