Peace of Mind Wellness | SimplePractice

Who would be receiving care?

My partner and me

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Client Preferences

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Are there any days or times you prefer for appointments? Please note that afternoon and evening times are very limited.

Are there any days or times you are NOT available for appointments? If yes, please list them. If not, write N/A.

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

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. You also agree not to submit any payment information, including credit or debit card details, through this form.