Contact Us Form

Please choose an Appointment Form

Legal Name of Client

First NameLast Name

If different from above, Client's Preferred Name:

Date of Birth

Date

What are the client's pronouns?

Current Date

Date

Patient Age

If the client is 17 or younger, what is the Parent/Guardian First Name, Last Name, and Date of Birth?

Name and DOB

Preferred Method of Contact?

Cell Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

E-mail

Address

Street Address

Street Address Line 2

CityState

Zip Code

Service Line

What type of therapy are you seeking?

Which type of Wellness Services are you seeking?

**** Please Note: These services may not be covered by your insurance provider.

What primary service(s) are you seeking after being referred from Family Tree?

Please note: The starred services may or may not be covered by your insurance provider. Nutrition therapy services are out of network with Optum insurances (Medica, UHC, UMR, UBH, BIND). At this time LynLake is not providing testing services.

In your own words, briefly tell us why you are seeking services

In a few sentences please explain what prompted you to reach out for services (i.e. goals for care, concerning symptoms, modalities you may be interested in...)

Do you have a gender preference in your medication provider?

Do you have a language preference in your medication provider? If so, other than English, what language do you speak?

Do you prefer a medication provider who specializes in prenatal care?

Do you currently take any of the following medications?

If you are not currently on any of the medications listed above, are you looking to be prescribed any controlled substances (such as stimulants for ADHD) or benzodiazepine for your diagnosis?

Nutrition therapy services are out of network with Optum insurances (Medica, UHC, UMR, UBH, BIND).

Are you enrolled in Medicare Part B?

Medicare Part B coverage is generally for those 65 and over, or for those with disabilities.

What is your payment method?

Which Medical Assistance: Medicaid/MA/PMAP/State Plan?

What is your preference for Self-Pay services?

What is your primary insurance?

Primary Insurance ID Number

Primary Insurance Group Number

Medicaid Number or PMI Number (applicable for Medicaid/PMAP/State Plans)

Do you have secondary insurance?

What is your secondary insurance?

Secondary Insurance ID Number

Secondary Insurance Group Number

What is your preference for attending sessions?

What are your location preferences for In-Person sessions?

Do you require an ADA-accessible site?

When are you available to attend appointments?

Do you know the name of a LynLake provider you'd prefer to work with? Please note that listing a name here is not a guarantee.

How did you hear about us?

Who can we thank for the referral?

Anything else you'd like us to know?

I understand that by submitting this form, a Referral Specialist will review my information and attempt to match me with a provider within 3–4 business days. My personal and demographic information, presenting concerns, and general appointment or provider requests will be treated as confidential and private. I understand I can reach out to referrals@therapy-mn.com with any questions.

Privacy policy: No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All the above categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.

SMS disclaimer: By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message (our message frequency may vary). Message & data rates may apply. Reply STOP to opt-out of further messaging. Reply HELP for more information. See our Privacy Policy.

By signing this document, I consent to the above.

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Service Details

Client Details

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Appointment Preferences

Referral Details