New Client Inquiry
Welcome to Sage Minds and thank you for reaching out! In the interest of getting back to you as quickly and effectively as possible, please provide the below information. We look forward to speaking with you!
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
DOB:
*
-
Month
-
Day
Year
Date
Preferred method of contact:
*
Please Select
Email
Phone Call
Text
Please use this space to list what days and times you would be available for sessions
i.e. Monday afternoons, weekday evenings, etc
How often are you looking to have sessions?
*
Please Select
Weekly
Bi-weekly
Multiple times a week
Other
Please use the below space to describe your reasons for starting therapy at this time
Please feel free to write as much or as little as you are comfortable with
In the past two weeks, have you experienced any thoughts of suicide or self-harm?
*
Please Select
Yes, suicidal thoughts
Yes, thoughts of self-harm
No
In the past two weeks, have you engaged in any self-injurious behaviors?
*
Please Select
Yes
No
How did you find us?
Please Select
Google/Search Engine
Referral
Social Media
Website
Word of Mouth
If you were referred or found us via word-of-mouth, please let us know by whom :
If you'd like to utilize your insurance benefits, please upload photos of the front and back of your insurance card so we can verify we are covered by your policy:
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