EmbodyMind Clinic Send Message

Who would be receiving care?

Your info

For insurance verification
Select the state you live in
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Reason for care
Administrative
Enter how you were referred to our services
Do not upload sensitive financial information such as credit card information.
Billing & Payment
How do you plan to pay?
You number is on the front of your insurance card
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Upload a photo of your insurance card
Client Preferences
Select a clinician from the list
For example: what you'd like to focus on, insurance or payment questions, etc.
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By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.