Noble Minds Community Mental Health Send Message

Who would be receiving care?

Your info

For insurance verification
Limited to 600 characters
Limited to 600 characters
If the client is a minor, under the age of 18, please provide this information
Limited to 600 characters
If they are in the 5th grade, the highest grade they have completed is 4th grade. If they just finished 5th grade and will be going into 6th grade, the highest grade they have completed is 5th. If college, or tech school, list date of graduation or GED from high school and the current progress, Example: Graduated in 2009 and just finished 5th year of college, working towards a Bachelors in Fine Arts, goal to graduate in 2017.
Reason for care
Please give as much information as possible including approximate time frames and place of service. For example: (I went inpatient for suicidal ideations when I was around 14, or in middle school, at "hospital, treatment facility name," or "I don't remember the name but it, 'and explain what you remember,' if you have been seen by a psychiatrist or out patient please share any diagnosis you have been given, medication prescribed or currently taking, when and who you saw, and for how long. Example: "I saw a therapist when I was 9 for around two years, we talked about my parents divorcing and how I could cope, I was struggling with school, and saw a psychiatrist or doctor who prescribed me Adderall, it didn't really work, made me feel..."
Limited to 600 characters
Domestic Violence is defined as, "physical violence, sexual violence, stalking, and psychological aggression (including coercive acts) by a current or former intimate partner"
Administrative
Enter how you were referred to our services
Billing & Payment
Please tell us about your insurance coverage or if you need information on private pay/sliding scale cost
Limited to 600 characters
Upload a photo of your insurance card
Client Preferences
When would you have availability to attend sessions?
(anything you want us to know prior to session that you may not want to discuss during session)
Limited to 600 characters

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.