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The Mind & Body Clinic
Welcome to The Mind & Body Clinic.  This form will better assist us in meeting your needs.

**Disclaimer: Completing and submitting this form does not place you under the care of The Mind and Body Clinic or any of the clinic's providers.  If you or someone you know is currently in a mental health crisis, please utilize a hotline local to Springfield, MO: 417-761-5555, dial 911, or take yourself to the nearest Emergency Room. **
In Google anmelden, um den Fortschritt zu speichern. Weitere Informationen
Email (to send intake documents) *
Request for specific provider *
Phone number (including area code) ###-###-#### format *
Client's First Name *
Client's Last Name *
Is the client an adult or minor? *
Client's Birthdate (Please double-check that you are entering the client's date of birth) *
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Have you been a client of The Mind & Body Clinic previously? *
The Mind and Body Clinic helps clients set up out of network benefits with their insurance network to seek reimbursement using a Superbill. Will you be self pay or need assistance with out of network benefits. *
Describe your availability for sessions.  *
Please let us know how you heard about us. *
If you were referred by another provider, friend, or family member please let us know who below: *
Goal of therapy? (optional)
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