BeWellLine Continuing Care
Create your client profile in Mindfuli today
Clinician Email
*
Please Select
jeremyr@mindfuli.com
geoffreyj@mindfuli.com
elizabethv@mindfuli.com
ginad@mindfuli.com
elijahw@mindfuli.com
nnekou@alterhealthgroup.com
marias@mindfuli.com
Please Select a Clinician Email from above
Facility/Referring Provider Name
Client Name
*
First Name
Last Name
Client Email
*
example@example.com
Provider Email
example@example.com
Provider Email (DOn't Use)
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Gender Identity
Please Select
Female
Male
Non-Binary
Transfeminine
Transmasculine
Agender
I don't know
Prefer not to say
Other
If Other, Please Explain
Client Phone
*
Please enter a valid phone number.
Provider Number
Please enter a valid phone number.
Please include any information that might be helpful for us to pair you with the right counselor.
Please upload discharge summary or treatment plan and a release of information.
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