First, please tell us a little about yourself.

This information will be kept confidential and helps us ensure were able to provide you with care.

Your primary home address

Tell us what brings you to therapy?

Select all that apply

Now, we have a few questions about your mental health history.



Our Promise

We’ll never share your personal information with anyone without your permission.




We follow HIPAA regulations, so your responses are always secure.





Client History.

If you or someone you know is in crisis, call 911 or the National Suicide Prevention Hotline 1-800-273-8255 right away.

Next, we’ll ask you a few questions about your mental health.

This will help your matching therapist better understand your mental health history and match you to the right care provider.
In the last 6 months, have you ever experienced symptoms of or been diagnosed with:
In the last 6 months, have you ever experienced symptoms of or been diagnosed with:
In the last 6 months, have you ever experienced symptoms of or been diagnosed with:

We've got you covered!

It gets much better from here. Get 1:1 help that works, and lasts — from the best in online therapy and psychiatry.

Verification of Benefits

Instructions:

Email VOB to verification@mindfuli.com  

Include the following:

  • Client Name
  • DOB
  • Client Address
  • Insurance Name
  • ID # 
  • Insurance Phone Number
  • Subscriber Name and Relationship
  • Referred By (Treatment Center)
  • Copy of the Insurance Card if available