Submit a request – Austin Mindfulness Center

Your email address

First Name

Patient's First Name (Not Parent's)

Last Name

Patient's Last Name (Not Parent's)

Patient (or Parent) Phone Number

Patient's Date of Birth

Have you been a client with us before?

AMC Newsletter: Free Mindfulness Workshop and learn more about mindfulness and our services(optional)

If you would like to opt out of receiving our newsletter, please check the box above.

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

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

I need help with:

Are you planning to use insurance?

I can afford:

Payment Options (Out-of-Pocket)

My insurance is:

Not accepted: BCBS (Couples or Family), EAP, 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:

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?

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.

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