Services Inquiry Form
Hello, and thank you for your interest in services with the Midwest Center for Transformational Change! We at the Center are excited to get to know you, and see whether we might be a fit for each other in our cocreative journey to support your health and becoming. If you have not yet, it is recommended that you review our website as a means of determining whether the services we offer would be a good fit for you: https://MWCFTC.com

First and foremost: the Center does not provide emergency services at this time to any except established clients. If you are feeling unsafe in any way, please do not wait. This form is not for emergencies, and this practice does not provide emergency services for the public. 

Some possible resources are
(1) Call your Primary Care Provider's (doctor, nurse practitioner, PCP) office, 
(2) Call 988 for a mental health emergency (US only), 
(3) Call 911 to summon law enforcement (US only), 
(4) Text 741741 for crisis text chat, 
(5) In Iowa, call Foundations 2 to talk to a crisis counselor at 800-332-4224,
(6) Visit https://suicidepreventionlifeline.org which provides chat services as well as services for the deaf and hard of hearing,
(7) Go to the emergency department of your local hospital. 

This form is informational in nature, and is the first step to arranging services at the Midwest Center for Transformational Change https://MWCFTC.com, a counseling practice based out of Cedar Rapids, Iowa, US. The founder, Anne Lindyberg (she/her, they/them), is independently licensed to provide counseling services to individuals in the states of Iowa and Illinois. Completing this form is required to schedule a consultation. Completing this form does not establish you as a client. Entries in this form are purged monthly for individuals who do not immediately begin services.

Scheduling a consultation is a two-step process: first, complete the form. And second, use the link at the bottom of the form to schedule a consultation. Entries in the form are not reviewed without a scheduled consultation appointment and will be purged. Please use the same email in this form and to schedule your consultation.

Entries on this form are stored directly in the practice's HIPAA-compliant Google Workforce account.

The Center typically takes 2 new clients per month. This is an average. At this time, all services are provided by Anne.

The Center's business hours are Tuesday through Saturday, by appointment only. At present, Anne schedules client appointments on Tuesdays, Wednesdays, Thursdays (appointments available from 9am-noon, 4-7pm) and Saturdays (9am-4pm). For most (80%) appointment slots, the client may choose an office appointment or telehealth. Thursday morning and noon appointments are conducted by telehealth only. HIPAA compliant Zoom is used for telehealth.

Engaging support for your healing transformation is a process, as much as the transformation is (video on the Satir Process of Transformational Change illustrates this well). While you may experience some challenges, and even experience disappointment in how the process of engaging services unfolds, it is designed to work well enough to ensure safety at every stage. If it does not come to pass that services can be provided the first time you reach out, it is possible that these challenges or barriers might be resolved in the future. You are encouraged to inquire back through email, and if you have specific questions about what is preventing services from being established at this time, or you would like a referral to a practitioner that provides similar services, Anne is willing to share suggestions and resources. At all times, the Center intends to treat you as the unique individual you are, with the kindness and respect we all deserve.

If it has been determined from the information provided that the practice is unable to offer services to you at this time and cannot offer a consultation appointment, general recommendations will be offered. If Anne can offer a specific recommendation, she will be happy to do so, although this is not always possible. Generally speaking, larger practices that are affiliated with hospitals and train students are good places to receive services in short order, using insurance, or for free or low cost.

That said, let's get started. Please complete this form to the best of your ability. It is necessary in order to schedule a consultation. A link to schedule the consultation will be provided at the end of the form. Your consultation appointment will be confirmed after this form is reviewed, if Anne believes she can offer you an appointment and be of appropriate support. There is no one question on this form the answer to which would automatically disqualify a person from receiving services.

At this time, only Anne reviews these forms. All information in them is kept confidential. Please answer all questions completely and honestly, without too much detail.
Email *
Please enter the name you prefer, and pronouns, if you would like. *
Please select the geographic region(s) from which you intend to receive services. If you live or work in any of these areas, please check them, even if you intend to receive services in the Center's office in Cedar Rapids, Iowa.

While Iowa has joined the interstate counseling compact, Anne is not prioritizing seeking permission to work with clients in any of those states at the moment. Nonetheless, if you regularly travel to one of these states, or another, please note the state under "other."
Are you filling this form out in order to receive counseling for yourself, or some other person? Please choose from below and add additional information under "other." 

At this time, priority is generally given to those who are willing and able to complete the form themselves. Counseling for individuals under the age of 18 and individuals under guardianship is only offered within the context of family counseling.
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Required
Please choose your age category, or the age of the potential client: *
Required
What is your availability for counseling sessions? The times given are the times that the practice schedules appointments with clients. Please check all that apply, and add notes if you like. If you are not available at any of the given times, you are unlikely to be scheduled. *
Required
How would you like your life to be different? Or to put it another way, what are your hopes for counseling? Use words that describe the experience of your life that you want most to have. *
Have you ever had counseling, therapy or life-coaching before? Would you describe it as helpful, not so much, or mixed? *
How are you planning on paying for counseling? Please include the name of your insurance company, including secondary and tertiary insurances if any, and add any comments you believe would be helpful. For a list of fees and current list of health plans being billed directly, please visit https://www.mwcftc.com/contents/contact/fees. Coverage for individual plans may vary. It is always best to check coverage with your health plan before scheduling. 

We regret that we cannot accept Medicare, nor any secondary insurance from individuals insured by Medicare. If you are a Medicare recipient who must receive services through use of Medicare, please look for a Licensed Psychologist, Licensed Independent Social worker (LISW), Advanced Registered Nurse Practitioner (ARNP), Doctor of Nursing Practice (DNP) or Psychiatrist for counseling. ARNPs, DNPs and Psychiatrists also prescribe medication; they frequently do not offer counseling/therapy, but some do. Those affiliated with hospitals and teaching institutions are more likely to take Medicare reimbursement. You can locate providers in your area who take Medicare by going to www.medicare.gov. We will be happy to work with you according to a private pay arrangement, if that is affordable for you. Please see our website link above for fee schedule.

The practice does not accept payment from third parties other than insurance companies, EAP companies with whom the practice is contracted, and HSA/FSA cards for family members. The Center will provide a superbill to facilitate reimbursement, at client's request, when client has paid the full fee.
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If services are established, your counselor will expect to be told the medication that you are being prescribed, including purpose, frequency and amounts, and the name, city and state (or country) of your prescriber. Some indication of this would be helpful here. If you do not feel comfortable giving complete information, please indicate (1) whether you are prescribed psychotropic medication, (2) how long you have been prescribed, and (3) whether you and your prescriber see the medication primarily as a "bridge therapy" (getting you to a level of functioning where you can engage in counseling or trauma therapy, and ultimately discontinuing one day if you desire it) or a "destination therapy" (you expect to take psychotropic medication for the rest of your life and it is seen as an absolute need for you). There is no right or wrong approach to medication. Being prescribed psychotropic medication will not automatically result in your appointment being denied. This practice does not employ or collaborate with a prescriber of psychotropic medication, but is pleased to communicate and collaborate with yours. *
Do you consume more than 7 alcoholic drinks per week on average, use THC, psilocybin, LSD, any illegal or unregulated mind-altering substance, or any psychotropic medication without the prescription and oversight of a licensed prescriber?

Please note that a "yes" answer will not disqualify you from receiving a consultation. Satir Model therapists value the independence of their clients and do not hold judgmental attitudes about self-managing behavior.
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Required
Have you been court involved in the last 12 months (other than traffic infractions, adoptions, divorce), or had an inpatient hospitalization for substance or mental health challenges within the last 12 months? If "yes," please offer a brief explanation. *
Required
How did you hear about Anne or the Center? If it was through a personal referral, please give the name of the individual who referred you, and your relationship to them. *
You are welcome to add additional comments if you choose. Anne may not have time to read beyond ~200 words. 
To schedule your free, 20 minute consultation
Thank you for completing this form. You are invited to schedule a free, 20 minute conversation which will be scheduled through Google Calendar conducted via the Center's HIPAA compliant Google Meet. You will require a Google account to schedule. Please proceed to the scheduler through this link. All scheduled appointment requests will be confirmed within 1 business day. Scheduling a consultation is not a guarantee that the consultation will be held. If the Center determines that it is unable to offer you services at this time, you will be provided feedback as to why that determination was made, and when services might be available for you.

If you do not have a Google account or find using the scheduler a challenge, you are invited to reach out to Anne via email at anne@mwcftc.com after completing this form. Please include some times when a Zoom or telephone consultation might be good for you. Consultations are never scheduled on Sundays, Mondays or holidays. Generally they occur at times of open availability in Anne's schedule. Phone/audio consultations are occasionally scheduled for a Friday. It may not be possible to schedule a consultation, but you will always receive a response. If you do not, please reach out through the website as we always get those messages.

Please schedule your consultation with the same attention to privacy that you would ensure for an appointment. If you'd like some guidance around this topic, here are two more links to Anne's article: https://bit.ly/ready4THmedium (or if there's trouble with the paywall https://bit.ly/Ready4TH)

Thank you for completing this form. It is our hope that you did not find the process onerous. As the Center proceeds through its own process of developing its ability to serve clients and the community, we appreciate the patience of those we aim to serve.
Additional Information
Anne Lindyberg is a qualified counselor and master's level supervisor (Iowa), licensed in the states of Iowa and Illinois, practicing Satir Transformational Systemic Therapy, also referred to as Satir Transformational Systems or the Satir Model, Deep Brain Reorienting (DBR) (level 2), and EMDR (basic training). Satir Transformational Systemic Therapy is an integrative model, fully inclusive of Cognitive Behavioral Therapy (CBT), focusing on the importance of the experience of the client, is trauma informed, and integrates the mind and body relationship using somatic and talk-mediated interventions. Anne has created some videos to further explain her counseling philosophy and posted them on her YouTube channel at https://www.youtube.com/c/AnneLindyberg or bit.ly/Lindyberg. Satir Transformational Systemic Therapy is a very effective method of short- or long-term counseling that requires the client to be engaged in the experience of their own lives, taking responsibility for creating the experience they wish to have and receiving support for that. In Satir Transformational Systems, the therapist provides support for this process.

It is expected that all clients intend to receive services while physically present in the states of Iowa or Illinois, or outside the United States in a territory without regulation for counseling services, or where language or other challenges make engaging helpful counseling services difficult. 

For clients who wish to use health insurance to pay for services, Anne expects to meet approximately weekly for at least 2-3 months (provided we both feel the fit is good; you are never obligated beyond the attendance policy). It is important to note that if insurance is to be billed--either directly or through reimbursement--or if FSA or HSA funds will be used, a diagnosis must be assigned to the client, which indicates medically necessary services. This is a requirement of the insurance companies. It is important to be aware that a diagnosis could follow an individual into the future and create challenges in achieving certain goals, such as obtaining health insurance, life insurance, or some employment. Anne strives to assign the least impactful, while still appropriate, diagnosis to clients for the purpose of creating the fewest challenges of this nature in the future. If this concerns you, please bring it up for discussion during your consultation. 

There will be no record of your consultation or of information entered into this form.

For private pay clients, no diagnosis is required if a superbill is not requested. 

A superbill must be requested in advance of a session, if client has not established they will want them at intake or in an earlier session, and is only available for a client who has agreed to and qualifies for a diagnosis.

The Center does not accept payment from third parties, other than health insurance plans or EAP plans, although there are certain instances where exceptions can be made. Anne does not take new clients for the purposes of assessment (producing a written letter or report for some purpose) exclusively or primarily. She will sometimes do assessments for existing clients on a case-by-case basis, according to her qualifications. Letters for emotional support animals are only offered to existing clients being seen regularly, and there will be a charge for them. Anne does not provide recommendations or support for disability services.

Satir Transformational Systems is also an extremely effective model for Life, Career, Organizational and Leadership/Executive Coaching. Clients who engage Anne's services under a private pay agreement and desire to avoid receiving a diagnosis will be considered coaching clients. It is also understood that coaching is a dynamic process for the benefit of the client and that Anne remains a qualified and licensed mental health counselor even when delivering coaching services. Because of this she will ask some questions in consultation or early sessions about history and current functioning and expects that they will be answered truthfully. If, even after significant work together, she believes a client could reasonably be assigned a diagnosis by healthcare providers, she will share this information when she believes it is in the client's best interest, or in response to the client's direct inquiry.

As mentioned elsewhere, completion of this form, and/or completion of a consultation, do not establish the individual as a client of Anne Lindyberg, LMHC, LCPC (practicing as the Midwest Center for Transformational Change). Emergency services are not provided by this practice. If you are feeling unsafe, as though you or another might come to harm through any means you are or might be unable to prevent, you are directed to immediately contact your primary care provider, mental health support by calling 988, law enforcement in your area using 911 services, Foundations 2 emergency services in Iowa at 800-332-4224, text services at 741741, or by contacting the resources at https://suicidepreventionlifeline.org which provides online chat services as well as services for the deaf and hard of hearing.
Covid-19, Infection Transmission Prevention Related Policies
The Midwest Center for Transformational Change, owned and operated by Connection Is, PLLC, is committed to minimizing the impact of the Covid-19 pandemic and maximizing safety for the Center's employees, clients, students, trainees and members of the community.

Anne Lindyberg has been vaccinated and received boosters against the Covid-19 virus, with the last booster received in October 2023. She maintains excellent health and has not, as yet, tested positive for the virus. Should a positive test occur, she would convert appointments to telehealth, and expects ALL clients to continue to receive treatment via telehealth. Clients who test positive for Covid-19 or are feeling ill are encouraged to receive services via telehealth and this change can be made even at the last minute. Nonwoven (surgical, KN95) masks are available at the office and may be worn by any client, provider or affiliated individual for any reason.

Medify brand Hepa H13 air filters are operating in the waiting room and office during business hours. These filters improve air turnover time from every 3 hours to every 30 minutes.

This policy has been instituted to provide maximum safety for individuals who work out of or visit our office, presently and in the future. It will be subject to periodic revision, and remain in place until Anne has determined that the risks posed by airborne viruses and their variants are sufficiently low to pose no threat to the most vulnerable, immunocompromised clients. Sources of information Anne uses in developing this policy include the CDC, WHO, interviews with doctors, scientists and individuals given by reputable news organizations. Control over this policy belongs to the business owner exclusively. Anne welcomes conversation about this and any policy as part of the process of deciding whether to receive services from or do business with the Center. This policy will be updated as changes in circumstances require.
Telehealth Expectations
It may be necessary, from time to time, for a client to receive services via telehealth, even if they prefer office appointments.

If office appointments are preferred, this can be accommodated most of the time. Anne sees clients in the office 80% of the time.

The Center offers all clients the chance to convert their office appointments to telehealth, even at the last minute, for any reason at all. This can be helpful when it comes to avoiding a late cancellation fee, and is intended to benefit the client as much as the practice. Telehealth appointments can be conducted when the client is ill, even from their bedroom and bed. Given the nature of the somatic (body-based) interventions Anne can offer, frequently such an appointment will make use of an illness, leaving a client feeling emotionally more fit upon recovery, in an enduring way.

Weather emergencies also occur, and sometimes Anne might be ill or traveling, and inform clients that their appointments will need to be converted to telehealth. Anne has not needed to convert to telehealth due to her own illness (or positive Covid test) yet, and telehealth appointments due to travel are generally kept to 4-8 weeks per year. At this time, clients are not required to schedule telehealth appointments when Anne's travel would require it. However, it is important to note that if they do not, they may experience an interruption in their treatment. If this situation would create undue strain or difficulty for you, Anne would not be the best choice for a therapist.

Telehealth appointments are conducted using HIPAA compliant Zoom. Skeptics have been surprised at how effective they can be. Information on how to prepare can be found in this Medium article on preparing for telehealth. (if you run up against the paywall, use this link.) 
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