Interest Form
Please use the form below to let us know what you are looking for and also to make scheduling faster and easier.  

1. Fill out this form (make sure you click submit!)
2. Schedule a call with our intake coordinator from the link on the confirmation screen after completing this form.

After you complete this form, schedule a call with us to discuss availability and to schedule the first appointment. 

If this is an urgent, life-threatening issue call 988, 911, go to a local hospital, or call your local crisis line.

DISCLAIMER: Please only send your basic contact information and we can discuss your needs in more detail over the phone. Completing this form does not constitute a therapy relationship, guarantee confidentiality, availability or appointments. 
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Email *
Name *
Phone *
Contacting About *
Required
Group Registration Only
Primary Insurance or Self Pay (Note: The insurances listed are the only ones we accept currently.  WE ONLY ACCEPT ANTHEM AND OPTIMA/SENTARA MEDICAID MCOs. We can NOT accept Optima Virginia Premier plans yet as we are/were not in network with Virginia Premier - we should be able to accept them in 2024)  *
Required
Secondary Insurance if Applicable
Age range of prospective client *
Required
Service(s) you are interested in, check all that may apply *
Required
Preferred location(s) for therapy appointments - check all that you are open to: *
Required
Your Availability (Other - Put in Comments Below)
9am-12pm
12pm-3pm
3pm-6pm
Monday
Tuesday
Wednesday
Thursday
Friday
How did you hear about Heart & Mind? *
Other important information, specific therapist request, etc.
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