Kind Mind Counseling | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Administrative

Referral source

How did you first hear about Kind Mind Counseling?

Billing & Payment

Payment method

How do you plan to pay?

Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Is there anything specific that you would like me to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.