Request a New Appointment

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

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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

No

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Unfortunately, we are unable to provide documentation services related to job/work readiness, workmen's compensation, disability determination, or legal issues (i.e. to attorneys; custody) given our scope of practice.

If you are unsure, you may list your specific request/concern in the Comment section below so we can best assist you.

Otherwise, you may exit this form at this time.

Thank you for contacting us.

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Location Preference* This field is required..

Online

In-Person

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

First Name

Last Name

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Contact Phone Number:* This field is required.

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Email* This field is required.

example@example.com

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

Phone

Text

Email

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Reason for Appointment* This field is required.

Individual Therapy

Parent Support for Behavioral issues (Brief Therapy: 4-6 telehealth sessions)

Testing: ADHD concerns and consultation

Testing: Learning concerns and consultation

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Referred By:

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

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New or Returning Client?* This field is required.

New Client (never been seen at MPG before)

Returning (previous MPG client)

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Client's Name* This field is required.

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

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Client's Age* This field is required.

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Client's School (If a student)

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

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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)

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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.

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

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1st Parent * This field is required.

Parent 1 First Name

Parent 1 Last Name

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1st Parent Email Address* This field is required.

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1st Parent Phone Number* This field is required.

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2nd Parent * This field is required.

Parent 2 First Name

Parent 2 Last Name

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2nd Parent Email Address* This field is required.

example@example.com

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2nd Parent Phone Number* This field is required.

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Behavioral issues in children and adolescents are often effectively treated with behavioral modification, an intervention implemented by parents. It does not replace individual therapy and sometimes both are needed. Are you interested in brief Parent Behavioral Management training (4-6 telehealth sessions)?

Yes, I am interested in Parent Training to help address behavioral challenges.

No, I am not interested in Parent Training.

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

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

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Email

example@example.com

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As a courtesy, if the Mililani Psychology Group is unable to offer an appointment, we can forward this completed form to independent clinicians (not MPG employees) who work at our clinic with your permission. Please check the boxes indicating which, if any, clinician you would like us to forward this form:* This field is required.

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

Carolyn Coldiron, LMHC (independent private practitioner) if MPG is unable to accept my case.

Please do not send this completed form to any clinician who is not an MPG employee.

Other

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As a courtesy, if the Mililani Psychology Group is unable to offer an appointment, we can forward this completed form to independent clinicians (not MPG employees) who work at our clinic with your permission. Please check the boxes indicating which, if any, clinician you would like us to forward this form:* This field is required.

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

Please DO NOT forward my information to anyone outside of the Mililani Psychology Group.

Other

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