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New Patient Form

Currently accepting new clients. Thank you for connecting with us and we look forward to helping you with your journey.

Patient Information

First Name

Last Name

Middle (Optional)

Preferred Name

Email

Phone

Birthday * required

Age

Gender (Optional)

Pronouns (Optional)

Occupation (Optional)

Preferred Therapy Modality

Have you had therapy before?

Briefly describe what you're struggling with.

Name of Insurance

Are you part of the Jeremiah Project?

Are you part of the Department of Correction?

How did you hear about us?

If you selected "referral", please type their name.

Best method of communication.

Best time of day to reach you?

Preferred Therapist

Thanks for submitting!

Thu Office Pic 3_edited.jpg

Connect with us

First Name

Last Name

Email

Phone

Briefly describe what you're struggling with.

What specific modality of therapy are you looking for?

If, you select "Other", please indicate below.

Name of insurance

Birthday * required

Ironwood Square Building

300 3rd Ave SE Suite 302

Rochester, Mn 55904

(P): 507-703-6377

(F): By email

**If you completed the new patient form, you do not have to fill out the 'connect with us' information box.

"Like a lotus flower, we too have the ability to rise from the mud, bloom out of the darkness and radiate into the world."

-unknown-

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