Center for Counseling and Wellness

Center for Counseling and Wellness Send Message

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Contact Method Preference

Please complete this form with all of the information you are able to provide. If you are having issues submitting this form, please try another internet browser. We will get back to you within 1-3 business days.

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Billing & Payment

Type of Insurance

Aetna Anthem Blue Cross Blue Shield of MN Cigna Health Partners Hennepin Health Medica MN Medicaid Medicare UCare United Healthcare Private Pay (No Insurance) Other

If you selected “other” as an insurance option, please clarify your insurance carrier.

What is your Individual Insurance ID and Group ID? (For insurance verification purposes)

Client Preferences

What brings you to therapy at this time?

Limited to 600 characters

When are you available to attend therapy?

Monday Morning Monday Afternoon Monday Evening Tuesday Morning Tuesday Afternoon Tuesday Evening Wednesday Morning Wednesday Afternoon Wednesday Evening Thursday Morning Thursday Afternoon Thursday Evening Friday Morning Friday Afternoon Saturday Morning

Do you prefer in-person or virtual therapy?

In-Person Virtual Open to Either/Both Other

Is there a specific type of therapist you would like to see? (Ex: age range, gender, areas of expertise, etc)

Is there a specific therapist you would like to see?

Jennie Zoe Kyle Kim Mackenzie Jasmine Jessica Sam Lindsay Emily

How did you hear about us?

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.