GET STARTED

Begin care, at your pace.

Complete the intake form below and we will reach out within one business day to schedule your first appointment.

WHAT HAPPENS NEXT

Three simple steps.

Complete the form

Share a bit about yourself and your insurance so we can verify coverage and prepare for your visit.

We verify and reach out

We confirm your insurance benefits and contact you within one business day to schedule your first appointment.

Confirm and prepare

Once scheduled, we send a secure video link, intake paperwork, and a brief telehealth setup guide.

NEW PATIENT INTAKE

Tell us a bit about yourself.

PERSONAL INFORMATION

Full Name

Date of Birth

Phone

Mailing Address

INSURANCE INFORMATION

Insurance Provider

Member ID

Group Number (if applicable)

Behavioral Health Number (if listed separately)

Insurance Card - Front

Insurance Card - Back

WHAT BRINGS YOU IN

Briefly, what would you like help with? (optional)

Privacy: This form is encrypted and HIPAA-compliant. The information you share is used only to schedule your visit and verify insurance. We never sell or share your data, and your information is stored securely with the same protections as your medical record.

ALREADY A PATIENT?

Use the patient portal instead.

If you are an established patient at LumenMind, the secure patient portal is the fastest way to schedule follow-ups, request refills, and message your provider.

If you are in crisis right now

This form is not for emergencies. If you or someone you know is in immediate crisis, please call or text 988 (Suicide and Crisis Lifeline) or 911 for emergency services. Additional resources are on our Patient Resources page.