Provider Interest Form- The Mind Card
Contact Information
Full Name
*
Practice/Organization Name
Provider Type
*
I am an individual provider
I represent a group practice
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State(s) of Licensure
Services Provided
In person
Telehealth
Are you interested in:
Accepting The Mind Card subsidy
Reduced cash-pay rate
Pro bono sessions
Payment Preferences
ACH
CHECK
PAYPAL
Any other information you would like us to know about you:
Submit
Should be Empty: