The Mind & Body Clinic

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Welcome to The Mind & Body Clinic. This form will better assist us in meeting your needs.

**Disclaimer: Completing and submitting this form does not place you under the care of The Mind and Body Clinic or any of the clinic's providers. If you or someone you know is currently in a mental health crisis, please utilize a hotline local to Springfield, MO: 417-761-5555, dial 911, or take yourself to the nearest Emergency Room. **

Email (to send intake documents) *

Request for specific provider

For Cassandra Minnick go to the following link: Cassandra's New Client Form

1st Available

E. Brooke Martin, LCSW

Ashley Perryman, LPC

Leah Musacchio, MSW Intern

Phone number (including area code) ###-###-#### format *

Client's First Name *

Client's Last Name *

Is the client an adult or minor? *

Adult

Minor

Client's Birthdate (Please double-check that you are entering the client's date of birth) *

YYYY

Have you been a client of The Mind & Body Clinic previously? *

Yes

The Mind and Body Clinic helps clients set up out of network benefits with their insurance network to seek reimbursement using a Superbill. Will you be self pay or need assistance with out of network benefits. *

Self-Pay

Out of Network Insurance (Superbill)

Describe your availability for sessions. *

Please let us know how you heard about us. *

Google

Psychology Today

Social Media

Referral from a professional

Referral from a friend or family member

Goal of therapy? (optional)

Submit

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