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New Client Request Form/ Waiting List
Welcome!
Thank you for reaching out to Healthy Growth Mindset, LLC.
We look forward to possibly working with you.
Please fill out this form and we will get back to you as soon as possible.
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* Indicates required question
Email
*
Your answer
Name of Potential Client
*
Your answer
Phone number
*
Your answer
Potential client’s date of birth
*
MM
/
DD
/
YYYY
Name of Parent or Guardian (if potential client is a minor > 18 years of age)
Your answer
What is the general topic/issue for counseling? (ex. Anxiety, Depression, Behavioral Problems, etc.)
Your answer
If potential client is a minor, are parents currently involved in family litigation (Divorce/Custody)?
*
Yes
No
Maybe
If yes or maybe, please briefly explain
Your answer
Is there an open Child Protective Services (CPS) case within the family members of the potential client?
*
Yes
No
Maybe
If yes or maybe, please briefly explain
Your answer
Is the potential client(s) involved in open civil or criminal litigation? (Court)
*
Yes
No
Maybe
If yes or maybe, please briefly explain
Your answer
I accept the following insurances. If your insurance is not on the list then I am not in network with them and you will be on my self-pay rate.
*
Blue Cross Blue Shield of Texas
Aetna
United Healthcare
Cigna
HealthSmart
Oscar Health
Oxford
Self-Pay
Other:
Home Address on file with Insurance
Your answer
Please enter your Insurance member ID # and Group #
Your answer
Information and Fees
Our self-pay fees can be found on our website. We also provide a limited availability of sliding-scale appointments.
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