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If you are in crisis and are unable to reach your therapist, call the Crisis line at (808) 832-3100, call 911, or proceed to your nearest emergency room immediately.

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Welcome to the Mililani Psychology Group

Thank you for considering us! We gather basic information here to better serve you - with a response usually within 3 business days via email. Please only include information you are comfortable sharing.

*10/1/22 UPDATE

We regret that we are currently unable to accept new patients for In-Person therapy after 1pm and ADHD/Learning evaluations.

When Is the Client Able to Meet?* This field is required.Please indicate the client's availability by checking the boxes below.

Insurance Coverage* This field is required.Mililani Psychology Group accepts HMSA, HMSA Quest, HMAA & UHA as your PRIMARY carrier. If you have any other insurance, the out-of-pocket cost is $150-$250 per hour (see Fee schedule).

Will the provider need to complete documentation for 3rd parties (i.e. letters, work leave, disability determination, job readiness, legal proceedings)?* This field is required.

Yes

Maybe

Unfortunately, we are unable to provide documentation services for workmen's compensation, disability determination, work place readiness, or legal-related issues (i.e. custody) given our scope of practice. Our role is therapeutic rather than evaluative. Thank you for contacting us.

Location Preference* This field is required..

Online

In-Person

Name of Person Completing This Form* This field is required.

First Name

Last Name

Contact Phone Number:* This field is required.

Email* This field is required.

example@example.com

Which of the following is acceptable for leaving messages:* This field is required.

Phone

Text

Reason for Appointment* This field is required.

Individual Therapy

Parent Behavioral Modification Training

Medication monitoring

Referred To:Please indicate if there is a specific provider requested.

Client Will Be:* This field is required.

Self

Child

Your Parent

Your Spouse

Other

New or Returning Client?* This field is required.

New Client (never been seen at MPG before)

Returning (previous MPG client)

Client's Name* This field is required.

Client's Date of Birth* This field is required.

Client's Age* This field is required.

Client's School (If a student)

Client's Grade (if a student)Current or more recently completed grade.

For minors, please confirm parental status:* This field is required.

Parents are Together

Parents NOT together: BOTH parents have LEGAL custody of the minor)

Parents NOT together: ONE parent has LEGAL custody of the minor)

If parents are not together (there is a separation, divorce or custody agreement), we require consent from BOTH of the minor's parents or legal guardians PRIOR to scheduling an intake appointment. Each parent or legal guardian MUST complete and sign the electronic Policies & Consents. Upon receipt of this completed form, we will send electronic Policies & Consents to each parent using a secure link or Client Portal using the email addresses provided.

In the event that only one parent has SOLE LEGAL custody, we may require supporting court documentation.

1st Parent * This field is required.

Parent 1 First Name

Parent 1 Last Name

1st Parent Email Address* This field is required.

1st Parent Phone Number* This field is required.

2nd Parent * This field is required.

Parent 2 First Name

Parent 2 Last Name

2nd Parent Email Address* This field is required.

example@example.com

2nd Parent Phone Number* This field is required.

Has the client been referred for any of the following reasons:* This field is required.

AD/HD

Depressed Mood

Anxiety

Behavioral Issues

Situational stress

Learning Differences

Self-harm

Suicidal ideation

Please feel free to share any additional comments or questions here.

Optional: List specific days of the week and times available.

example@example.com

As a courtesy, if the Mililani Psychology Group is unable to offer an appointment, we can refer you to independent clinicians who work at our clinic with your permission. Please check the boxes that apply below. *Please forward this completed form to:* This field is required.

Dr. Madelyn Butac-Roeske (independent private practitioner) if MPG is unable to accept my case.

Maile Kimura, LMFT, BCBA (independent private practitioner) if MPG is unable to accept my case.