New Client Appointments

If you are a new client and you would like to request an appointment with one of our providers, please fill out the confidential HIPAA secure form below. By providing us with the information requested, we can more easily and quickly check your benefits and coverage, and pair you with a clinician who best meets your needs. Once you have completed the form, our Intake Coordinator will contact you within 24 hours.

Don’t like online forms? That’s okay too! Give us a call at 651.447.3605 and we can take your information by phone as well.

If you are an existing client, please schedule directly through our client portal here.

New Clients Only: Fill in the information below to request an appointment for yourself or someone else.

First Name*

Last Name*

Street Address*

Street Address 2

City*

State*

Zip Code*

Phone*

In order to expedite communication and scheduling, may we text you at this number?

Yes

Email*

Type Your Email Again*

If you are requesting the appointment for someone else, what is your full name and relationship to the client?

What services are you inquiring about?*

Due to high demand, some of our therapists may not be accepting new clients. We suggest choosing several possible therapists you are interested in so we can check their availability for you. If you have a first choice, please choose them below.*

Who is your second choice for a therapist?

What days/times are you generally available for therapy? Please be as specific as possible with dates/times (e.g., Mondays between 3pm and 8pm).*

Before we can can begin providing services to any client, we must have insurance information. We will do a full check of your benefits and will email you with details of your coverage so there are no surprises! All information entered is transmitted through a HIPAA compliant form and will be kept confidential.

Legal Name (as it appears on client's insurance card)

Sex (that is listed on your health insurance)

Client's Preferred Gender Pronouns

Is the client under the age of 18?*

Date of Birth*

Name of Primary Insurance Company (or indicate if you are not using insurance)*

Group Number (put NA if not using insurance)*

Policy Number (put NA if not using insurance)*

Name of Secondary Insurance Company (if applicable)

Group Number for Secondary Insurance (if applicable)

Policy Number for Secondary Insurance (if applicable)

Are you or a member of your family a current or past Cardinal Psychotherapy client?

Yes

Please provide a brief summary describing your goals in therapy or the type of support you are seeking.*

Do you prefer in person or virtual sessions?*

Please verify your request*