Creative Mind Counseling, LLC

Your info

First name

Last name

Phone

Name you go by

Date of birth

Insurance-recorded sex designation (for billing purposes):

(Only required if using insurance for services)

Male Female X

Pronouns

Administrative

Referral source

Enter how you were referred to our services

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.