Interest Form
**We are currently in the process of transitioning our electronic record keeping software. These forms will be received and reviewed, though our response time will be delayed. Thank you for your patience as we update our systems to better serve our clients, prospective clients, and the Richmond community.
 
Please use the form below to inquire about our services. We have very limited availability for therapy at this time, especially after 3pm. We do have availability in our Tame Your Tiger program. We will contact you promptly via phone or email if we have a clinician available who may meet your needs. Completing this form does not guarantee availability or appointments. We can provide other resources to call if we are unable to meet your needs at this time.

Caseworkers and those making referrals for CSA or FAPT funded services, use this link:
https://docs.google.com/forms/d/1UTj5mMxNEpc3553eDZX0E_6gHB_QIgvpneo2CUH1RvM/edit

 If this is an urgent, life-threatening issue call 911, go to a local hospital, or call your local crisis line.

DISCLAIMER: The contact form below is not HIPAA compliant. Please only send your basic contact information and we can discuss your needs in more detail over the phone.
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Email *
How did you hear about Heart & Mind? *
Name *
Email *
Phone *
Contacting About *
Required
Insurance or Self Pay (Note; The insurances listed are the only ones we accept) TYT Program is self pay only (not covered by insurance) *
Required
If we do not have an available provider who is in-network with your insurance, are you open to self-pay sessions with a Resident in Counseling at a rate of $75 per appointment? *
Age range of prospective client *
Required
Types of Services you are interested in *
Required
Preferred location(s) for therapy appointments: *
Required
Your Availability (Other - Comment Below)
9am-12pm
12pm-3pm
3pm-6pm
Monday
Tuesday
Wednesday
Thursday
Friday
Comments:
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