Beautiful Minds Medical Waitlists

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Use this form to easily provide your information to Beautiful Minds Medical in order to be added to waitlists for our mental health services. Scheduling for all providers occurs using a waitlist. Wait-times vary from provider to provider. We strive to do our best to provide our patients with the highest level of care possible. We will reach out to you to confirm details with you as soon as possible.

Email *

Please provide your name: *

Please provide your Date of Birth: *

This information will be used to verify compatibility with provider age requirements.

YYYY

Please provide the best phone number to contact you on: *

We will use this contact information only to confirm necessary information related to waitlist/appointment status, etc.

What is your most preferred method for us to contact you? *

By Phone Call

By Text Message

By Email

Are you a resident of CA? *

All of our providers are primarily licensed in CA. We are unable to render services to patients permanently residing outside of CA.

Yes

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