Contact Us
Submit this form if you would like to be contacted regarding services.
Name
*
First Name
Last Name
Date of Birth
*
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Who would be receiving care?
*
Me
My partner and I
My child/dependent
My family
Someone else
What service is being sought?
*
Individual therapy
Couples therapy
Family therapy
Group therapy
ADHD screening assessment
Other
Preferred clinician
*
Please Select
Lori Brown-De Alba, MA, LMFT (MN)
Nicky Arduino, MA, LMFT (MN)
Maggie Foltz, MA, LMFT (MN)
Kaylee Olson, MSW, LICSW (MN, IL)
Anyone
Best fit
Referral source
*
Please Select
Friend/family
Medical/Mental Health provider
Print advertisement/billboard
Event
Online Search
Psychology Today
Social Media
Other
How can we help?
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*For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.
*By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.
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