top of page
1. Client Information
Gender Identity
Multi-line address
Preferred Contact Method
Phone Call
Text Message
Email
Preferred Language
Is this client a minor (under 18)?
Yes
No
2. Emergency Contact
3. Insurance Information

If uninsured or unsure, leave blank — a team member will assist you.

Insurance Provider
4. Services Requested

Select all that apply.

Multi choice
5. Referral Information
How did you hear about Mindfulness Healing?
6. Reason for Seeking Services
7. Mental Health History

This section is optional. You will still complete a full assessment with your clinician at your first appointment.

Have you previously received mental health treatment?
Yes
No
Have you ever been hospitalized for mental health concerns?
Yes
No
Are you currently taking any medications?
Yes
No
8. Safety Screening

Within the past 30 days, have you experienced any of the following? Check all that apply.

Safety Screening
bottom of page