Requester's Name *

First Name

Last Name

Client's Name (Minor or Partners only)

Please add the client's name if different than your own (for example, a minor or partner's name for a couple's therapy request)

First Name

Last Name

Client's Age (Minor only)

If completing this form on behalf of a minor, please add the client's age so we can be sure to match them with a therapist with the right training and experience.

First Name

Last Name

Phone *

(###)

###

####

Text response OK? *

Yes

No

Therapist

Please choose the therapist(s) you would prefer to see (if you have a preference)

Ada Rosas

Alycia Novotny

Branden Phillips

Chrissy Hollerman

Jordan Maciej

Kjerstin Rydeen

Krissy Jorgensen

Lisa Nemitz

Mandy Wannarka

Paul Reps

Rachel Todd

Services *

Please check the services at Mindful Wellbeing you are interested in:

Therapy (virtual or in-person)

DBT + Yoga Group (in-person only)

Mama Be Well (virtual support group)