Intake Form

I am seeking care for:*

Myself (Adult)My child (Under 18)Another Adult (Spouse, Parent, Family Member, etc.)

Patient's Name:*

My Name:

My relationship to patient:

Email address:*

example@example.com

Phone Number*

Please enter a valid phone number.

Phone Number:

If you prefer text follow-up

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.