Submit a request – Austin Mindfulness Center

Your email address

First Name

Patient's Legal First Name (Not Parent's) - As shown in ID / Insurance Card

Last Name

Patient's Legal Last Name (Not Parent's) - As shown in ID / Insurance Card

Patient (or Parent) Phone Number

Client's Date of Birth

Have you been a client with us before?

Please select all additional forms in which you authorize Austin Mindfulness Center to contact you.

We will contact you via email with some options to help you get started. An Email is required to create a client portal account. This form is HIPAA secure, but your email, phone, or messages may not be.

Are you currently residing or living in Texas?

I am looking for:

Custodial Parent's First Name (or Legal Guardian)

Custodial Parent's Last Name (or Legal Guardian)

Partner's First Name

Partner's Last Name

Partner's Email

Partner's Phone Number

I need help with:

I prefer:

Preferred Office Location

Primary Reason for seeking Therapy

Additional Issues for seeking Therapy (Check All that Apply):

Are you planning to use insurance?

Please attach a copy of your insurance card to this form (Both Sides)

I can afford:

https://www.austinmindfulness.org/rates-and-insurance

My insurance is:

Not accepted: Couples or Family sessions, EAP,some HMO plans, Magellan, Medicare or Medicaid plans.

Insurance Member ID

Please include full ID (3 letter prefix for BCBS Insurance)

Insurance Group Number

Legal Sex (If using insurance, select the sex on file with your insurance policy. Insurance companies require this information for billing)

Are you the Primary Subscriber listed on this insurance plan?

Primary Subscriber's First Name

Primary Subscriber's Last Name

Primary Subscriber's Date of Birth

Do you have a preference for one of our therapists? (optional)

Please make sure to read visit your preferred therapist profile before selecting an option. Some of our therapists may not be accepting new clients (waitlist only) or may not accept your preferred payment option (insurance)

I can meet on a weekly basis during any of these times (Please provide as many options as possible that could work for your schedule. The more options we receive from you, the more clinicians we can pull from to get your best fit):

Suggested Frequency: Please keep in mind we highly suggest a minimum of 6-8 weekly sessions when starting therapy, along with a regular weekly commitment. This will contribute to building a trustful relationship with your therapist and prioritizing your process of healing and growth.

How did you hear about the Austin Mindfulness Center?

Have you had a recent hospitalization or IOP treatment?

What matters you the most?

Please share with us what is most important to you when choosing a therapist so that we can share with you the best options to help you get started

Description

Is there anything else we should know before our team reaches out to you? If not please submit "NA". A member of our support staff will respond in the next 2 business days.

Attachments(optional)

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