Mind Over Matter Psychiatric Solutions

Mind Over Matter Psychiatric Solutions Send Message

Your info

First name

Last name

Email

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Reason for care

What is the reason for seeking care?

Anxiety Adjustment issues Behavioral issues Depression Grief Relationship issues Insomnia Trauma Other

What service is being sought?

Psychiatric Evaluation Single Session Service Therapeutic Conversation Emotional Support Animal Letter Not Sure

Administrative

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Billing & Payment

Payment

I understand that all of the services that I receive are self-pay and will not be billed to my insurance provider.

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I understand that I will be charged immediately after services have been completed

Yes No

Client Preferences

Preferred Communication Method

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

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.