Skip to content
Skip to content
(951) 585-3357‬
office@amindfulyou.com
A Mindful You Logo
A Mindful You Logo
  • INTAKE
  • SERVICES
  • OUR TEAM
  • RESOURCES
  • FEES
  • LOCATION INFO
  • POLICIES
    • Practice Policies
    • Opt-out preferences
    • Privacy Statement (US)
    • Imprint
  • LOGIN

Intake form

  1. Intake form
Intake formACMEAdmin2025-04-29T21:21:17+00:00

Step 1 of 3 - Patient Details

33%
Are you currently experiencing thoughts of suicide?
If you’re feeling overwhelmed or struggling with thoughts of suicide, please know that you are not alone. There are people who care about you and want to help. You can reach out to the Suicide & Crisis Lifeline by calling 988 or visiting 988lifeline.org for immediate support. If you are in an emergency, please call 911 or go to the nearest emergency room. Your life is important, and reaching out for help is a strong and courageous step.

Please select a staff member you'd like to meet with.

Patient Details

Are You a:(Required)
OK to Leave a Message?
Patient Speaks
MM slash DD slash YYYY
Have You Been Court Ordered to Therapy??(Required)
Drop files here or
Accepted file types: pdf, jpg, png, doc, docx, webp, gif, Max. file size: 256 MB.
    * Multiple files accepted
    Name of Parent or Legal Guardian(Required)
    Is There a Custody Agreement?(Required)
    Drop files here or
    Accepted file types: pdf, jpg, png, doc, docx, webp, gif, Max. file size: 256 MB.
      * Multiple files accepted
      Are Restrictions Specified for Either Parent in the Agreement?(Required)
      Are custody Issues present?(Required)

      Insurance Info

      Do you have Insurance?
      Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.
      Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.
      Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.
      Are You In Network?(Required)
      Have You Been Seen Yet?

      Benefits 1 of 2

      Is Provider In Network?
      Type of Service Requested
      MM slash DD slash YYYY
      Claims Mailing Address
      Clear Signature
      Clear Signature
      MM slash DD slash YYYY
      Copyright A Mindful You | All Rights Reserved | Website powered by ACME Logo
      Page load link
      Manage Consent
      To provide the best experiences, we use technologies like cookies to store and/or access device information. Consenting to these technologies will allow us to process data such as browsing behavior or unique IDs on this site. Not consenting or withdrawing consent, may adversely affect certain features and functions.
      Functional Always active
      The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network.
      Preferences
      The technical storage or access is necessary for the legitimate purpose of storing preferences that are not requested by the subscriber or user.
      Statistics
      The technical storage or access that is used exclusively for statistical purposes. The technical storage or access that is used exclusively for anonymous statistical purposes. Without a subpoena, voluntary compliance on the part of your Internet Service Provider, or additional records from a third party, information stored or retrieved for this purpose alone cannot usually be used to identify you.
      Marketing
      The technical storage or access is required to create user profiles to send advertising, or to track the user on a website or across several websites for similar marketing purposes.
      Manage options Manage services Manage {vendor_count} vendors Read more about these purposes
      View preferences
      {title} {title} {title}
      Intake Form

      Step 1 of 3 - Patient Details

      33%
      Are you currently experiencing thoughts of suicide?
      If you’re feeling overwhelmed or struggling with thoughts of suicide, please know that you are not alone. There are people who care about you and want to help. You can reach out to the Suicide & Crisis Lifeline by calling 988 or visiting 988lifeline.org for immediate support. If you are in an emergency, please call 911 or go to the nearest emergency room. Your life is important, and reaching out for help is a strong and courageous step.

      Please select a staff member you'd like to meet with.

      Patient Details

      Are You a:(Required)
      OK to Leave a Message?
      Patient Speaks
      MM slash DD slash YYYY
      Have You Been Court Ordered to Therapy??(Required)
      Drop files here or
      Accepted file types: pdf, jpg, png, doc, docx, webp, gif, Max. file size: 256 MB.
        * Multiple files accepted
        Name of Parent or Legal Guardian(Required)
        Is There a Custody Agreement?(Required)
        Drop files here or
        Accepted file types: pdf, jpg, png, doc, docx, webp, gif, Max. file size: 256 MB.
          * Multiple files accepted
          Are Restrictions Specified for Either Parent in the Agreement?(Required)
          Are custody Issues present?(Required)

          Insurance Info

          Do you have Insurance?
          Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.
          Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.
          Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.
          Are You In Network?(Required)
          Have You Been Seen Yet?

          Benefits 1 of 2

          Is Provider In Network?
          Type of Service Requested
          MM slash DD slash YYYY
          Claims Mailing Address
          Clear Signature
          Clear Signature
          MM slash DD slash YYYY
          Submit Your Resume

          Upload your resume with cover letter stating areas of interest. (population and geographic locations)

          Preferred method of contact(Required)
          Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.
          Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.
          Go to Top