MIS Therapy Appointment Request Form
We're glad you're taking the first step to feeling better.

We applaud your ability to be vulnerable and transparent about where you are in life. These steps are not easy, and they take strength and courage. Whether for you, your children, your family, or your spouse, we hope this first steps leads you to a place of hope excitement for the future that is to come.

If you are looking to request an appointment, you've made it to the right place! Please fill out as much as possible and our appointment coordinator will contact you within 48 hours. We take our time to hear your concerns and connect you with the best case that fit your needs.

If you are not the client, please answer the questions below in regards to the client that will be seen at MIS Therapy. Our Appointment Coordinator will be in touch very soon to talk to you more about scheduling your first appointment.
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Name of the Person Filling out the Form *
Name of the Client(s) *
Age of the client to be seen *
Best phone number to contact to coordinate care *
Email address of the person who would complete the intake paperwork? (If the client is over 18, please provide their email) *
What do you hope to gain (for the client) in going through the therapeutic experience? *
Zip Code of where you live *
Are you currently looking for in office or Telehealth sessions? (Check all that apply) *
Required
Are there specific types of therapy you are looking for at this time? *
Required
What are the best times to schedule an appointment? *
If you are hoping to complete this via insurance, which insurance do you currently have? (Please note, we are only in network with non-medicaid plans) *
Is there anything specific you'd like us to know that will help us determine the best coordination of care? *
Check here is completed by an MIS staff member.
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