Make an Appointment - Counseling & Therapy

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Counseling & Thearpy

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Individual (Adult & Child) Counseling
Couples Counseling
Family Counseling
School-Based Mental Health
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Request an Appointment

To request an appointment, please fill out the form below. One of our intake coordinators will be in contact with you to schedule your visit.

Client Information

Full Name

Birthdate (mm/dd/yyyy)

Contact Information

Phone Number

Address

City

State

Zip Code

Is this appointment for you or a someone else?

Self

Someone Else

If you marked “Someone Else” please include your name and relationship to the client indicated above.

Is client is a minor?

Yes

If client is a minor, Parent First & Last Name

Is parent contact information the same as above?

Yes

If No, please include parent address, phone and email below.

Insurance Information

If able please provide your insurance information. We will receive your information securely and keep it confidential. Insurance information is not required to submit form.

Primary Insurance Name:

Policy Holder’s Name

Group Number

Policy ID

Policy Holder’s Date of Birth

Secondary Insurance Name:

Policy Holder’s Name

Group Number

Policy ID

Policy Holder’s Date of Birth

Location Preference

Stillwater

Hudson

Center for Grief & Loss

School-Based

If you picked school-based, which school is being attended?

Were you referred by your child’s school counselor? If yes, please list name here.

Other Information

What are your concerns bringing you to therapy?

Appointment Preferences
(ie: after 3:00pm on Monday and Tuesday)

Prefer to call?

Make an appointment by phone, or speak with someone to learn more! Contact FamilyMeans intake department at: 651-439-4840. Due to COVID-19, please note that some staff are still working remotely and response time may be delayed.

651-439-4840 | 800-327-3203
Fax 651-439-4894

Main Office
1875 Northwestern Avenue South
Stillwater, MN 55082

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