INTAKE FORM

If you are Interested in our Services, please fill this out and we will get back to you. The more information provided, the better we can serve you. If you do not hear back from us in a week, please check your spam and email us at info@catalystinsightcollective.com

First and Last Name

Phone

Email Address

Age and Gender/Preferred Pronouns

How Did You Hear About Us?

What services are you looking for?

Mental/behavioral health conditions (Please click any that you have been diagnosed with)

Anxiety

Depression

Bipolar 1

Bipolar 2

PTSD

OCD

ADHD

Addiction

Eating Disorder

Schizophrenia or other psychotic disorder

Personality Disorder

Other

I have never been diagnosed with a Mental/Behavioral Health Condition

Are You Currently:

Self harming (i.e., cutting, etc)

Experiencing a manic episode

Experiencing active suicidal thoughts

Experiencing passive suicidal thoughts

Have you had suicide attempts in the past?

None of the above

If you have been in therapy in the past or are currently in therapy, explain past and current treatment and the therapist you have seen and are seeing

Physical health history: (Please click any of the following)

High blood pressure

Cardiovascular (heart) problems

Seizures

History of stroke

Liver problems

Sleep apnea

Have you had any major surgeries recently?

None of the above

What insurance do you have?

Thanks for applying! We’ll be in touch soon.

CONTACT US

2855 Anthony Lane South Suite 140 St. Anthony, MN 55418

Thanks for submitting!

2855 Anthony Lane South Suite 140 St. Anthony, MN 55418

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