Intake Form

I am seeking care for:*

Myself (Adult)My child (Under 18)Another Adult (Spouse, Parent, Family Member, etc.)
Patient's Name:*
Patient's age:
My Name:
My relationship to patient:
For medical decision-making purposes, please indicate the current legal relationship between the child’s parents:

MarriedDivorcedSeparatedNever marriedOther (please specify below)
If you selected ‘Other’ above, please indicate the current legal relationship between the child’s parents:
Email address:*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number:
If you prefer text follow-upFormat: (000) 000-0000.
Preferred follow-up:*

EmailPhone
Before proceeding, we want to ensure you understand our billing model.

North Star Behavioral Health is a private-pay practice and is out of network with all insurance plans. This means that payment is due at the time of service. We will provide you with a superbill statement, which you can submit to your insurance company for potential out-of-network reimbursement.
Would you like to continue with a private-pay practice?*

YesNoI'm not sure
We understand! If you’re looking for an in-network provider, we recommend checking your insurance company’s directory or Psychology Today to explore options that work with your plan.
Referral source:*
Please specify your referral source:
Please enter the clinician’s name and/or practice name:
Please describe what you'd like help with:*
Are you seeking:*

Psychiatric Medication ManagementPsychotherapyBoth (Psychiatric & Therapy)Not sure
Are there good times that work best for us to reach you by phone?
Please Review & Confirm Before Submitting:*

I acknowledge that this form is for appointment requests only and does not guarantee availability.I understand that North Star Behavioral Health is a private-pay, out-of-network practice.I consent to being contacted by phone or email.
Should be Empty: