New Client Contact Form - Mind & Melody Therapy Services
Please complete the following information in order to begin intake process. I will contact you for a 15-minute consultation to discuss. Thank you! 
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Currently, I only provide services to Pennsylvania residents due to licensure restrictions. Can you confirm that you are a Pennsylvania resident?
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First & Last Name  *
Date of Birth  *
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Email  *
Phone Number (optional) 

You agree to receive informational messages (appointment reminders, account notifications, etc.) from Mind & Melody Therapy Services. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at cmorrison@mindmelodytherapy.com. You can opt out at any time by replying STOP.  See Messaging Terms and Conditions and Mobile Messaging Privacy Policy below or via links provided: 
Privacy Policy: https://www.mindmelodytherapy.com/privacy-policy
Terms and Conditions: https://www.mindmelodytherapy.com/terms-and-conditions
How did you hear about us?  *
Required
Interested Service *
What do you want to accomplish in therapy?
What insurance do you have?  *
To check insurance coverage, feel free to provide your member ID number...
Availability  *
Please list any additional information you would like me to know:
Messaging Terms & Conditions 
"Messaging Terms & Conditions:
You agree to receive informational messages (appointment reminders, account notifications, etc.) from [Company name]. Message frequency varies. Message and data rates may apply. For help, reply HELP or email us at [Company general email address]. You can optout at any time by replying STOP. "
Mobile SMS Messaging Privacy Policy
Information collected:
We may collect information, such as name, phone number, and email address.

Use of information collected:
We may use the information we collect to perform the services requested including billing, customer service, appointment reminders and other administrative requests.


Sharing of information collected:
We may share information we collect with payment processors, legal authorities, partners so that these service providers can perform their normal duties. We do not share, sell, rent, or trade any information provided with third parties for promotional purposes.


As a current or prospective customer, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text us HELP at any time to receive help.
You understand that the messaging frequency may vary. Messaging & data rates may apply.
Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.
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