MindWell Counseling Screening Intake
Submit this form and a MindWell staff member will reach out to get you scheduled for your first appointment!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How would you like us to reach out?
*
Phone Call
Email
Text
When would you like us to reach out?
*
Mornings (9am - 12pm)
Early afternoon (12pm - 2pm)
Late afternoon (2pm - 5pm)
What insurance do you have?
*
What type of session do you prefer?
*
In-Person
Virtual
No Preference
Provider Preference
*
Male
Female
No Preference
Preferred Availability
*
Weekdays
Weekends
Mornings and Afternoons
Evenings
Other
What type of therapy are you looking for?
*
Individual
Couple
Family
Neurofeedback
Group
Other
Please share a little about why you are seeking therapy.
*
Any Additional Comments
Submit
Should be Empty: