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

**Please note that clinicians in our network are only accepting appointment requests for telehealth (phone or online) at this time.**

You will receive a call or email from a clinician screener within 2 business days to discuss your request.
(Please make sure to check your spam or junk email box if you don't hear from us in a timely manner)

**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 *
Age *
Phone Number
e-mail address
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 format (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) *
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: *
Please let us know how you heard about us!
Submit
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