Therapy
in New York and Vermont

Getting Started with MindWell

Fill out our brief questionnaire to share your needs and availability.
Hear from a team member within 2-3 days.
Start therapy within a week for most clients, though availability may vary.

Still Have Questions?

We’re here to support!

Wherever you are, we'll meet you there.

Complete your confidential intake to help us match you with the right MindWell provider.

Step 1 of 13 HIPAA Secure & Confidential

Get Started

What type of therapy are you looking for?

Select the type of therapy *

Adult Therapy: 18+ Child & Adolescent Therapy: under 18 Couples & Relationship Therapy

What Brings You In?

Briefly describe why you are seeking therapy at this time *

Provider Preference

Do you have a preference for your provider's gender? *

Yes, I have a preference No preference

Select gender preference(s) *

Female Male Non-binary

If your preferred provider is unavailable, would you like to: *

Wait for a provider matching my preference Match with the next available provider

Safety Information

Does your child have previous or current involvement with Child Protective Services? *

Yes No

Has your child attempted suicide in the past year? *

Yes No

In the past year, has your child: had a psychiatric hospitalization; been admitted to an IOP or PHP; or been to the emergency department for mental health reasons? *

Yes No

Please fax the hospital intake and discharge records to MindWell's HIPAA secure fax at 607-241-9972. Appointments cannot be scheduled until records have been reviewed. *

Acknowledged. I will fax records to MindWell's HIPAA secure fax at 607-241-9972.

Safety Information

Do you have previous or current involvement with Adult or Child Protective Services? *

Yes No

Have you attempted suicide in the past year? *

Yes No

In the past year, have you: had a psychiatric hospitalization; been admitted to an IOP or PHP; or been to the emergency department for mental health reasons? *

Yes No

Please fax the hospital intake and discharge records to MindWell's HIPAA secure fax at 607-241-9972. Appointments cannot be scheduled until records have been reviewed. *

Acknowledged. I will fax records to MindWell's HIPAA secure fax at 607-241-9972.

Safety Information

Has either of you had serious thoughts of suicide in the past year? *

Yes No

Has either of you attempted suicide in the past year? *

Yes No

In the past year, has either of you: had a psychiatric hospitalization; been admitted to an IOP or PHP; or been to the emergency department for mental health reasons? *

Yes No

Please fax the hospital intake and discharge records to MindWell's HIPAA secure fax at 607-241-9972. Appointments cannot be scheduled until records have been reviewed. *

Acknowledged. I will fax records to MindWell's HIPAA secure fax at 607-241-9972.

Child's Information

Has your child seen a MindWell provider in the past? *

No Yes

Child's Legal Name *

Child's Date of Birth *

Home Address *

Parent / Guardian Information

Parent/Guardian Completing Form *

Your email address *

Your phone number *

- -

Custody Information

Are you the primary custodial parent/guardian? For minors, the custodial parent/guardian must consent to treatment. If there is shared custody, both parents/guardians are required to sign consent forms prior to the start of treatment. *

Yes No

Does the child have another legal parent/guardian? *

Yes No

Are they a custodial parent/guardian? *

Yes No

Your Information

Have you seen a MindWell provider in the past? *

Yes No

Are you currently a college / university student? *

Yes No

Your Legal Name *

Date of Birth *

Email address *

Phone number *

- -

College / University name *

College / Term-time Address *

Do you have a different home address (e.g., for breaks)? *

Yes No

Home address state *

New York Vermont

Home Address *

Partner Information

Information about the other person in the relationship.

Partner's Legal Name *

Partner's Date of Birth *

Partner's email address *

Partner's phone number *

- -

Does your partner share the same home address as you? *

Yes No

Partner's Home Address *

Insurance Information

For therapy services, MindWell is in-network with CDPHP, including CDPHP Child Health Plus and CDPHP Medicaid managed plans. Aetna is in-network for Adult and Child & Adolescent therapy services only (not Couples).

All other insurances are out of network. You will be provided with an estimate of self-pay fees upon scheduling.

Select the client's category of health insurance. *

CDPHP - In Network: The exact costs depend on your CDPHP plan, and any applicable deductibles, co-pays, or limitations CDPHP Child Health Plus or CDPHP Medicaid managed plans - In Network Aetna - In Network: Adult and Child & Adolescent therapy only (not Couples) All Other Insurance Providers - Out of Network: Self-pay, you will be provided with an estimate upon scheduling Medicaid or Medicaid Managed - Out of Network: NYS Child Health Plus, Vermont Green Mountain Care, Dr. Dynasaur (as primary or secondary) Medicare or Medicare Advantage - Out of Network: either primary or secondary coverage

MindWell is not able to accept Medicare, Medicare Advantage, or Medicaid insurance, as either primary or secondary coverage. This includes Dr. Dynasaur, Green Mountain Care, and NYS Child Health Plus. * *CDPHP Child Health Plus and Medicaid managed plans are accepted and in-network. CDPHP Medicare plans are out-of-network and not accepted. I would like to schedule as a self-pay client and understand that claims cannot be submitted to Medicare/Medicaid for reimbursement.

Insurance Details

Select the client's primary health insurance company *

Is the client covered by any Medicaid insurance? Select YES if there is ANY Medicaid coverage (primary or secondary). * Includes: Dr. Dynasaur, NYS Child Health Plus, NYS Essentials Plan, Green Mountain Care, Medicaid Managed Care, Medicaid Fee-for-Service, Medicaid Advantage.

Yes No

Is the client covered by any Medicare or Medicare Advantage insurance? *

Yes No

MindWell is not able to accept Medicare, Medicare Advantage, or Medicaid insurance. * I would like to schedule as a self-pay client and understand that claims cannot be submitted to Medicare/Medicaid for reimbursement.

Policy Holder Information

What is the relationship of the primary policy holder to the client? *

Self Parent/Guardian Spouse

Name of the primary insured * If client is the primary insured, select "Self" above.

Date of birth of the primary insured *

Policy ID/Number *

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Upload picture of back of insurance card. jpg, png, or pdf only

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Terms & Conditions

This form is secure and HIPAA-compliant. Your information is protected and used solely for the purpose of scheduling care.

MindWell's Practice Policies: https://www.mindwellcenter.com/policies

MindWell's Terms of Use: https://www.mindwellcenter.com/termsofuse

MindWell's Privacy Policy: https://www.mindwellcenter.com/privacy

SMS Consent

By submitting, you agree to receive text messages at the provided number from MindWell Psychology. Message frequency varies, and standard message and data rates may apply. You can OPT-OUT at any time. Reply HELP for assistance, STOP to opt out.

I accept the Terms and Conditions, Practice Policies, Privacy Policy, and SMS Consent. *

This form is secure and HIPAA-compliant. Your information is protected and used solely for the purpose of scheduling care.This form is not intended for urgent or emergency situations. If you or someone you know is experiencing a mental health crisis or emergency, please do not use this form. Instead, contact one of the following resources immediately: (1) Suicide & Crisis Lifeline: Call 988 or 1-800-273-8255 (2) Crisis Text Line: Text HOME to 741741 (3) Or go to your nearest emergency room.

Therapy
in New York and Vermont

Getting Started with MindWell

Still Have Questions?

Wherever you are, we'll meet you there.

Get Started

Location & Format

What Brings You In?

Current Concerns

Weekly Availability

Provider Preference

Safety Information

Safety Information

Couples Therapy Questions

Safety Information

Child's Information

Parent / Guardian Information

Custody Information

Additional Parent / Guardian

Your Information

Partner Information

Insurance Information

Insurance Details

Policy Holder Information

Tell Us How You Found Us

Terms & Conditions

Thank you!

Therapy in New York and Vermont

Getting Started with MindWell

Still Have Questions?

Wherever you are, we'll meet you there.

Get Started

Location & Format

What Brings You In?

Current Concerns

Weekly Availability

Provider Preference

Safety Information

Safety Information

Couples Therapy Questions

Safety Information

Child's Information

Parent / Guardian Information

Custody Information

Additional Parent / Guardian

Your Information

Partner Information

Insurance Information

Insurance Details

Policy Holder Information

Tell Us How You Found Us

Terms & Conditions

Thank you!

Therapy
in New York and Vermont