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Individual Patient Intake Form

Looking for Couples Counseling? Please complete our Couples Intake Form!

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Please note that we do not accept Kaiser or Tricare insurance.

Sex
Please upload a photo of you insurance card
Upload supported file (Max 15MB)

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "submit" you agree to hold Heart & Mind Counseling Services harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Thanks for submitting! ​ We will email you our intake paperwork and an invitation to our telehealth platform, TherapyPortal, within two business days.​

If you do not receive our intake paperwork in that timeframe, please give us a call at 410-324-2216.

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