Interna Mental Health

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Referral Form for Services

Email Address
*

Client First Name

Client Last Name *

Client Preferred Name *

Client's Pronouns (optional)

Client's phone number *

Client Date of Birth *

YYYY

Client guardian name and contact information (if applicable) *

Are you a returning or current client?

Yes

Clear selection

Insurance Information *

Insurance Network *

I understand it is my responsibility to confirm and understand my insurance benefits for mental health therapy services, and to confirm Interna is in-network with my specific insurance plan

Client is being referred to/interested in *

Individual therapy

Couple's therapy

Family therapy

Coaching

Group therapy

Is client wanting services via telehealth or in-office? *

Telehealth/virtual

In-Person (Northeast Minneapolis, MN)

In-Person (Eagan, MN)

In-Person (Inver Grove Heights, MN)

In-person (at any location)

Required

Is there a specific therapist/coach/practitioner you are interested in working with? Clinician blurbs can be found here: https://www.internamentalhealth.com/meet-the-team

If your preferred provider is not accepting new clients, would you like us to connect you to a different provider?

*Please note, not every clinician keeps a waitlist*

Yes, please refer to different provider

Clear selection

Tell us more about what you are looking for and/or your presenting concerns *

How did you hear about Interna Mental Health?

Submit

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