Appointment Request Form
PLEASE NOTE: This form is encrypted to ensure the privacy of your information.
Any and all information disclosed on this form is confidential and will not be sold or distributed to any third parties with the exception of Insurance billing purposes.
Thank you. Our staff will be with you shortly.
*As it would appear on your insurance card
Includes zip code, city, and state
Read our bios on our website if you have any questions about our providers!
No preference - First available provider
Social Media (Facebook, Instagram, etc.)
Online Ad/Web Search
Do you give permission to your UMN referring provider to coordinate initial documentation and scheduling with your Acacia provider?
Further treatment documentation involving non-intake scheduling will need a Request of Information (ROI).
Community Member / No Academic Affiliation
Please indicate the services you're interested in
*In an effort to make our services more accessible, we've launched our new platform Reach that offers video therapy services. These sessions are done remotely using a secure platform, and in most cases, can be billed to your insurance as an in-person session would. Signing up for video therapy services may reduce your total wait time. Other benefits include flexible scheduling and having access to a larger network of therapists with varying specialties and backgrounds. If you'd like to learn more, visit
Psychiatry & Medication Management
Reach Video Therapy*
Which days and times are you available?
Will you be available for appointments during Summer?
Health Insurance Provider
Blue Cross Blue Shield
Do you have a secondary insurance plan?
Check yes if you are covered by more than one health insurance plan. If you provide incomplete or inaccurate information, you may be responsible for the balances we are unable to collect from your insurance plan(s)
I'm not sure, I will find out and confirm before my first appointment.
Would you be willing to pay out of pocket for an out of network insurance provider to speed up your scheduling process? Sessions are billed at a $150 rate.
Many of the clinicians at Acacia are "In-Network" providers, which means they accept your in-network insurance benefits and you are only responsible for your mental health copay. However, new clinicians at Acacia often require time (4-8 months) to get credentialed and be on insurance panels. These clinicians are "Out-of-Network" and bill at a rate of $150. We can still bill these claims to your insurance, and you may or may not have out of network benefits that cover a portion of that rate (We can run an eligibility check prior to scheduling you). These clinicians often have more availability in their schedule because they cannot see as many clients as an in-network provider would be able to. If you are in need of more immediate services and willing to see an out of network provider, please check "Yes" below.
Please check this box to indicate that you read and agree with our Insurance Policy Statement
Send a picture/scan of your insurance card (both sides) to either Email: email@example.com or Text: 612-299-1090
Never submit passwords through Google Forms.
This form was created inside of Acacia Counseling & Wellness.
Terms of Service