Email CARE Counseling

ASK & SCHEDULE WITH OUR ADMINISTRATIVE TEAM

Name *

First

Last

Email *

Phone *

Would you like to schedule an appointment?

Yes
No
Not at this time

What can we help you with... *

If scheduling an appointment, please feel free to include any therapist preferences you may have here. If you prefer to leave blank, simply put "care"

First preferred Session Date / Time (limited availability after 4pm CT)

Date

Time

We will do our best to schedule your session closest to this date/time possible, based on clinician availability.

Second preferred Session Date / Time (limited availability after 4pm CT)

Date

Time

We will do our best to schedule your session closest to this date/time possible, based on clinician availability.

What other days of the week are you available to schedule?

Monday
Tuesday
Wednesday
Thursday
Friday

Preferred Location (please choose top three) *

Open to Telehealth
Bloomington
Clifton/Loring Park
Edina
Franklin/Minneapolis
Mankato
Maple Grove
Mendota Heights
Plymouth
St. Louis Park
Woodbury

Date of Birth *

Legal sex (insurance purposes only)

Female
Male
Non-binary
Transgender
Other
Choose not to disclose at this time

Consent to call or text

Preferred timeframe(s) (7-4pm CT) and/or days for callback

If consenting to call or text

Phone only
Text only
Both

If different, what is your relationship to the client?

(e.g., referring provider, parent/guardian)

To help us verify your insurance, do you wish to provide this information now or later

Provide now
Provide over the phone (we will call at date/time indicated above)
Upload to the EHR once appointment is scheduled

Insurance Carrier Name

(e.g., BCBS of MN, HealthPartners MA, Medicare, Medicaid)

MemberID

(i.e., policy number and/or letters).

Where did you hear about CARE Counseling?

If referred to CARE by a provider, you may list them here.

PLEASE NOTE: This form is not intended for urgent matters and will not be read immediately.

For urgent assistance:

Dial 988 for the National Suicide and Crisis Lifeline.
Dial 911 for emergency services or go to the nearest emergency room.

Thank you for reaching out to us. We look forward to connecting with you soon!

Meet Clinicians

We’re united by our commitment to providing effective, relevant, and innovative mental health support at all stages of your journey. Click Here to find out more about who we are, where we come from, and how we live out CARE’s mission every day.