The Center for Self | SimplePractice

The Center for Self Send Message

Who would be receiving care?

Me

Someone else

Your info

First name

Last name

Email

Phone

Name you go by

Date of birth

Gender

What are your preferred pronouns?

Reason for care

What brings you to therapy at this time?

Limited to 600 characters

What mental health treatment have you had in the past? What did you like or not like?

Limited to 600 characters

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

Please list name of insurance such as Blue Cross Blue Shield, Wellmark, HealthPartners

Limited to 600 characters

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend Flexible

Preferred clinician

Select a clinician from the list

How would you like to be seen?

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Preferred day to be seen

Monday Tuesday Wednesday Thursday Friday Weekend Flexible

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.