ModernMind Counseling & Wellness

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

What sex is on your insurance policy?

For insurance verification

State

Select the state you live in

Zip Code

Pronouns

Reason for care

What's bringing you to therapy right now?

Tell us in your own words — the more context, the better we can match you with a clinician who meet's your needs.

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Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

We accept BCBS PPO plans, Aetna, and Aetna State Health Plan. Please note, we do not accept the following: - Healthy Blue - Blue Local - High Performance Network Plans - Some SC BCBS plans only allow Emergency Services

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Insurance card upload

Upload a photo of your insurance card

Client Preferences

Preferred appointment times

Morning Afternoon Evening

Preferred modality

What do you look for in how a therapist works with you? (direct and challenging, gentle and nurturing, somewhere in between, etc.)

Feel free to mention anything that's worked or not worked for you in past therapy.

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Anything else you would like us to know?

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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.