Interest Form

Doro Mind Care Request Form

Getting started with Doro Mind
Our goal is to connect you with the best care possible as quickly as we can. To better understand your needs, we use this from to gather information and context.

If you have questions or if you would prefer to speak with a staff member about Doro Mind you can schedule a welcome call using this link or you can message us anytime in the Doro Mind app.

Doro Mind is not a crisis service. If you are in need of immediate assistance for a mental health crisis please dial 988 to speak with a trained counselor immediately.
Individual seeking care for myselfFamily caregiverClinical providerOther
Your Full Name*

First NameLast Name
Your Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Email Address*
example@example.com
Your Phone Number
Please enter a valid phone number.
YesNo
Yes, I approve receiving text messages.No, I do not wish to receive text messages. Please use email or phone call.
How did you hear about Doro Mind?

Information for person seeking services

Please provide the following personal information for the individual you are seeking care for.
Name of the person you are seeking services for:

First NameLast Name
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Yes, please contact them directlyNo, please use my contact information

Additional contact information

This contact information will be used to share appointment information.
Email of person seeking services:
example@example.com
Phone Number of person seeking services:
Please enter a valid phone number.

Insurance and financial information

Doro Mind may have income based grants available to reduce costs. Please complete the following information in order to determine your eligibility.
Family annual income:
Number of people in the household:
Health Plan Type*
The person receiving care's health insurance plan type
Health Plan*
The person receiving care's health insurance plan
If other health plan, please describe:
YesNo

Doro Mind Care Request Form