Appointments

To get started with Mind Matters Collective, please complete this form for yourself or the person you’re referring. By submitting, you agree to receive a brief voicemail or email from us with more information. We’ll be in touch within 1–2 business days.

Who is this request for?

Myself

Someone Else

Name

First Name

Last Name

Are you a new, returning or current client?

Date of birth of the person this request is for:

If you’re completing this for someone else (like a child), please enter their DOB below. We collect a date of birth to ensure we’re following the right consent and privacy laws for minors.

YYYY

(If under 18) Parent/Guardian Name:

Phone

(###)

###

####

How Did You Hear About Us?

What type(s) of Service are you seeking?

Which location do you prefer?

Insurance Coverage?

Please provide the name of your current insurance plan (if applicable)

Preferred Availability?

Mornings (8-11am)

Afternoon (12-4pm)

Early Evening (5-7pm)

Open to First Available

Reason For Services?