Intake Request Form

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Intake Request Form

Please fill out the requested information, which will help us find a better match for your treatment. Once your form has been assessed by our staff, we'll contact you with the options available for clinical services.

Email *

Name (first and last) *

Phone Number (mobile preferred) *

Are you seeking therapy for yourself, or someone else? *

Myself (or others and myself)

Someone else (and not me)

Which type(s) of therapy are you seeking? *

Please check any options that apply.

Individual therapy

Group therapy

Couples/Relationship therapy

Family therapy

Adolescents/Teen therapy

Sex therapy

Other:

Required

Briefly describe, if you can, the reason(s) you are seeking therapy at this time.

Please include any clinician/specialty requests here.

Availability for Sessions: Mon-Thu

Please indicate any time-of-day you are available, for a minimum 45-minutes, for recurring virtual therapy sessions. We will reach out to you to discuss the exact available times which may match your schedule. Kind Mind Psychology does not give appointments without having a regularly-scheduled time slot.

Mornings

Afternoons

Evenings

Mondays

Tuesdays

Wednesdays

Thursdays

Availability: Fridays (Morning/Afternoon ONLY)

Mornings

Afternoons

Fridays

Where will you (or the primary patient) be physically present during therapy?

Please note: if you do not reside in NC, NJ, or NY, we can provide coaching sessions, which are not eligible for insurance benefits/reimbursements.

New York

New Jersey

North Carolina

Other (in the United States)

Other:

When is the soonest date you (or they) will be ready to start regularly-recurring sessions? *

YYYY

Please indicate any/all payment options you would like us to consider.

If your insurer is not listed here, we are likely not in-network. Please enter your insurer's name in "other," and we can discuss out-of-network options.

Self-Pay

Medicaid OR Uninsured

Aetna (In-network)

Cigna (In-network)

Meritain (In-network)

Northwell (In-network)

Aetna Student Health: The New School (In-network)

Other:

Required

A copy of your responses will be emailed to the address you provided.

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This form was created inside of Kind Mind Psychology.