What service do you want to start? *

Choose which type of service(s) you want to schedule

Therapy/Counseling

Psychological Testing/Evaluation

Patient's Name *

Name of person starting services

First Name

Last Name

Name of Person Completing This Form *

First Name

Last Name

Patient's Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Mailing Address *

The mailing address associated with the patient's insurance

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which do you prefer? *

Select if you prefer virtual/video appointments, in-person appointments, or either

I prefer virtual, but am open to in-person

I prefer in-person, but am open to virtual

Either would be just fine (virtual or in-person)

I only want virtual appointments

I only want in-person appointments

If attending in-person, which locations might work? *

Waconia

Chanhassen

Edina

None - I want virtual appointments