Appointment Request
Welcome to Healthy Minds! Please fill out the form below and click "Submit" when you are finished.

Filling out this form immediately places you on our Appointment List, which all of our therapists have access to. If a therapist has an opening in their schedule, and the needs you have coincide with what they can offer, that therapist will call you directly to make an appointment.

***PLEASE NOTE THAT BEING PLACED ON OUR APPOINTMENT LIST DOES NOT AUTOMATICALLY GUARANTEE THAT YOU WILL GET AN APPOINTMENT. WE ARE NOT ABLE TO FULFILL ALL APPOINTMENT REQUESTS THAT WE RECEIVE. YOU WILL EITHER HEAR FROM THE CLINICIAN WHO CAN TAKE YOU AS A CLIENT, OR SOMEONE WILL CONTACT YOU REGARDING FINDING OTHER CLINICIANS IN THE AREA***

We strongly encourage you to reach out to other clinicians in the area if you are in need of immediate help. Your primary care physician, insurance company, or the Psychology Today website (www.psychologytoday.com) can all be good sources of information on other local counselors.

**Please note that we are not a crisis service. If you are experiencing a mental health crisis, please call crisis services through Northwestern Counseling and Support Services at 524-6555.

We are committed to your privacy. By completing this form, you are agreeing to our privacy practices, which are included in the link below.
https://docs.google.com/document/d/130TWiWS0pZ12omD9_zXD6KcgVpIJw1pKa_7KnFTvYSg/edit?usp=sharing

Name *
Your answer
Age *
Your answer
Phone Number
Your answer
e-mail address
Your answer
Preferred way of contact *
Preferred therapist *
Would you consider seeing a therapist of the non-preferred gender if that is the only therapist available? *
Preferred location (check all that apply) *
Required
Would you consider your non-preferred location if it is the only place with an available therapist? *
Type of Insurance (If you have Medicare, please include the secondary insurance as well) *
Your answer
Times available for an appointment (check all that apply) *
Required
Type of service needed *
Required
General description of what you would like to work on in counseling: *
Your answer
Submit
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