New Patient Information

Hi!

We at KindMind Health, PLLC are excited about possibly working with you!

The following questions help us know that we are the best fit for you.

Please fill them out honestly and completely so we can match you with the most appropriate provider

*If you are in crisis, please stop and call 911 or the crisis line at 602-222-9444.

KindMind Health, PLLC is not a crisis center and does not take crisis calls.

New Patient Screening Form

*This screening form does not mean you have been accepted as a patient.
Upon receipt of form, our staff will review it and contact you to schedule an appt, confirm your appt if you requested one through the portal, or offer you alternative resources!

Steps for Healing

Step 1

Identify need & readiness for change

Step 2

Fill out screening form.

Step 3

After completion of our pre-screening form, we will be able to review your request and admin staff will reach out to schedule an appointment and/or provide you with resources and referrals if we are unable to accept you as a patient.

First and Last Name

Birthday

Phone

Select an Address

Reason(s) for reaching out for services * Required

ADHD

DEPRESSION

ANXIETY

PTSD

OCD

MOOD SWINGS

BARIATRIC EVALUATION

BODY DYSMORPHIA

CURRENT ISSUES WITH SUBSTANCES

PAST ISSUES WITH SUBSTANCES

ANGER MANAGEMENT

OTHER

Please list any medical or physical health conditions you may have (i.e. cardiac issues, diabetes, high blood pressure, etc). If no medical or physical health conditions, please write N/A

Are you currently seeing a mental health professional? If Yes, please provide name and contact information for provider. If no, please write N/A

Do you have health insurance? If Yes, please identify which insurance you have, Name of insured and date of birth if not yourself, ID number, & Group Number. If no insurance, please write Self-Pay.

If you are currently on medications, please provide names, dosages, and last fills below. If not on any medications, write N/A.Please also list any Past Trials of Medications. If no past trials of medications, please write N/A.

Thanks for submitting! Our admin staff will contact you shortly to set up an appointment!

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