Mustard Seed REQUEST A CONFIDENTIAL APPOINTMENT
Mustard Seed REQUEST A CONFIDENTIAL APPOINTMENT
Name
Name
*
First
Last
Phone
Phone
*
-
###
-
###
####
Email
*
Who Is This Appointment For?
This appointment is for:
*
This appointment is for:
Myself
My Child / Dependent
If for a child, Child’s Name
Preferred Contact Method
How would you like us to contact you?
*
How would you like us to contact you?
Phone
Email
Best Time to Contact You
*
Best Time to Contact You
Morning
Afternoon
Services Requested
Type of Service You Are Seeking:
*
Type of Service You Are Seeking:
Counseling / Psychotherapy
Medication Management
Both Counseling and Medication Management
Not Sure (Please advise)
Not Sure (Please advise)
Insurance Information
Do you plan to use insurance?
*
Do you plan to use insurance?
Yes
No / Self-Pay
Insurance Provider (if applicable)
Member ID (optional)
Brief Message (Optional)
Please share any brief information that may help us prepare for your request (note this is optional)
Confidentiality & Submission
PLEASE READ Before Submission
*
PLEASE READ Before Submission
I understand this form is not monitored for emergencies. If I am experiencing a mental health emergency, I will call 911 or go to the nearest emergency room.