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Intensive Outpatient Therapy
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Intensive Outpatient Therapy
Out Intensive Outpatient Therapy programs are designed....
Please fill out the form below to speak with our Program Intake Coordinator. We will attempt to reach out to you within 24-48hrs.
Client Name
(Required)
First
Last
Client Date of Birth
(Required)
MM slash DD slash YYYY
Email Address
(Required)
Client Phone Number
(Required)
Primary Contact (If different then client)
First
Last
Contact Phone Number
Contact Relationship to Client
Insurance Information
If you have your insurance information, you may provide below. Otherwise, our Program Intake Coordinators can take any additional information during your initial conversation.
Insurance Carrier (if applicable)
First Choice
Second Choice
Third Choice
Insurance Policy Details (if applicable)
Member ID
Group ID
Contact Preferences
Best Time to Contact
Do you have preferred days and/or times?
Care Needs
What areas are you seeking support for?
(Required)
Anxiety
Depression
Trauma
Grief
Life Transitions
LGBTQ+
Behavioral Issues
Communication Skills
Chronic Pain
ADHD
School Performance Concerns
Bipolar
Anger Management
Personality Disorders
OCD
Caregiver Burnout / Parenting
Sleep Concerns
Sports Performance
Substance Abuse or Dependency
Psychosis / Schizophrenia
Chronic Stress
Eating Disorders
PTSD
Are you looking to seek care in-person or virtually?
(Required)
In-person
Virtually
Both
If in-person, which locations would work best for you?
Eagan (Adult)
Maplewood (Adolescent)
Anything else you wish to share that would help us understand how we can support you?
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