Contact — Mindful Body Therapy & Wellness

Name

First Name

Last Name

Phone

(###)

###

####

Are you planning to use insurance?

Yes

Please provide the name of your insurance if applicable:

Please tell us about what you are looking for:

Please provide what you are hoping to focus on in therapy, the days/times you are available, & if you prefer in person or virtual sessions (these responses are required to move forward)

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Mindful Body Therapy and Wellness harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Yes, I want to submit this form & agree to the terms of use. *