Liberated Mind Counseling and Health Center

Liberated Mind Counseling and Health Center Send Message

Who would be receiving care?

Me

My partner and me

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Your info

First name

Last name

Email

Phone

Name you go by

Reason for care

What is the reason for seeking care?

(select all that apply)

Anxiety Attentional difficulties Career counseling Depression Existential, Loss of meaning / Life-transition Faith Transition / Deconstruction Grief Men's issues Relationship issues Retreats / Workshops / Group Therapy Trauma Women's issues Other

Administrative

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Billing & Payment

Insurance details

For now, simply indicate the name of the insurance company we will be billing for your appointments. If payment will be direct / Private Pay, please indicate this here as well. You can see a list of our insurance partners on our website under FEES, as well as instructions on how to seek reimbursement with other companies that would be considered Out-of-Network.

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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.