Mind Matters Collective, LLC

Mind Matters Collective, LLC Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Preferred name

(If different from your legal name)

Reason for care

What is the reason for seeking care?

Select any that apply

Anxiety Attention difficulties Depression Difficulty regulating or managing emotions Feeling detached or disconnected Grief & loss Obsessive–compulsive concerns (OCD) Panic Perinatal/postpartum concerns Phobia(s) Post-traumatic stress (PTSD) Relationship with food, eating and/or movement difficulties Relational issues Self-identity concerns Stressors related to recent life changes or transitions Trauma (including complex trauma) Other (please provide details in the “Is there anything else?” section below)

What type of services are you seeking?

Therapy Medication Management Both

Administrative

How did you hear about us?

Are you a new, returning or current client?

New (never been seen at MMC) Returning (previous client at MMC)-please email info@mindmatterscollective.com Current client of MMC (wanting to schedule an addtl service) — please email info@mindmatterscollective.com

Billing & Payment

Payment method

Please indicate your anticipated method of payment

Insurance Information

(If applicable — Aetna, Blue Cross Blue Shield (BCBS), Health Partners (HP), Hennepin Health, Medica, Minnesota Medical Assistance (MA), One Health, UCare, United Behavioral Health (UBH), etc.)

Limited to 600 characters

Client Preferences

Preferred appointment times

Morning (8-11am) Afternoon (12-4pm) Early Evening (5-7pm)

Preferred Location

Is there anything else you’d like to share that would help us better support your care?

(Any added context, focus areas, or practical questions, etc)

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

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.