Intake Request Form
You can contact us by text or call at (210)-325-5809 or by email at intake@battlingminds.com
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth
/
Month
/
Day
Year
Date
Insurance/ Payer (if applicable)
Preferred Session Type
Please Select
In-person
Virtual
Either
Referral Source
Please enter days that would work for you to be seen
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please enter a time frame that works for you
Morning
Mid day
Afternoon
Any scheduling details you would like to clarify:
Submit
Should be Empty: