Greater Minnesota Trauma Center

Greater Minnesota Trauma Center 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

Sex at birth

For insurance verification

State

Select the state you live in

Street Address & City

Reason for care

What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Substance use Trauma Other

What kind of care is being sought?

Psychotherapy Parent Education (Not covered by insurance) Supervised Visitation (Not covered by insurance) Parental Capacity Evaluation (Not covered by insurance)

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Administrative

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Insurance Type

If you have insurance, please enter who your insurance is through, Member ID, & Group ID. If you do not wish to use insurance, type N/A

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

While specific appointment times cannot always be accommodated, we will make every effort to meet scheduling preferences whenever possible.

Morning Afternoon Evening No preference

Preferred modality

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

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If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.