Request an Appointment — Bloomington Mental Health Services

Appointment Request

To schedule a therapy appointment or to obtain additional information about any of our counseling services, please fill out the form below or give us a call at 612-968-6097.

We are committed to your privacy and ask that you use this form for general questions or messages to the practitioner. Do not include confidential or private information regarding your health condition in this form or any other form on this website.

If you're a new client, please complete the following forms and bring them to your first therapy session.

Client Psychotherapy Intake Form
Limits of Confidentiality/Therapy Cancellation Policy

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

Authorization to Disclose Information Form

Name

First Name

Last Name

Phone

(###)

###

####

Preferred Date & Time

Message

Need help scheduling your appointment?