Client's Name Required
Client's Phone Required
Additional info or requests
Email Required
I am interested in counseling for Required
---- Abuse Academic Issues Addiction and Substance Abuse ADD/ADHD Anxiety Attachment Issues Autism Spectrum Disorders Bipolar Chronic Health Issues Co-Dependency Depression Diagnostic Assessment Eating Disorders Family Change and Divorce Grief and Loss Infertility Issues Learning Disability LGBT Issues Life Transition Obsessive Compulsive Disorder /OCD Panic Disorder / Panic Attack Parenting Phobias Post Traumatic Stress Disorder / PTSD Postpartum Anxiety Postpartum Depression Postpartum OCD Relationship Difficulties Self Esteem & Self Image Self Harm Sexual Violence Sleep Issues / Insomnia Stress Management Suicide Work / Life Balance Other
If selected "other" please list here
Location Required
---- Hudson, WI Eau Claire, WI Maple Grove, MN Lakeville, MN Roseville, MN
Insurance Required
To expedite scheduling, please also provide the following information. Thank you!
Full Legal Name of Client
Date of Birth
Full Address (including city, state and zip code)
Insurance ID/Member Number
Insurance Group Number (if applicable)
Email address for patient portal (Please note, this email must be for the client if 18+ or a legal guardian for minors.)
Any scheduling preferences? (Please note, we have very high demand so the more flexible you are, the more likely we are to have options for you.