Attuned Mind Counseling Services

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

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Client Preferences

Preferred appointment times

Please list specific days/times (morning, afternoon, evening) you are available for recurring sessions.

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Preferred clinician

Select a clinician from the list

Reason for care

How can we help you?

You may put as much or as little information here as you like to help us understand your needs and goals for treatment.

Limited to 600 characters

Administrative

Preferred contact method

When is the best time to contact you?

Session Setting Preference

Preferred Office Location (if applicable)

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.