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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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 4 business days via email.

Please only include information you are comfortable sharing.
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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.
Monday
Tuesday
Wednesday
Thursday
Friday
8a - 11a
11a-2p
2p-5p
8a - 11a
11a-2p
2p-5p
Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Monday
Tuesday
Wednesday
Thursday
Friday
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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).
HMSA PPO/HMO/Fed
HMSA Quest
HMAA
UHA
Out of Pocket (Cash)
N/A
Primary
Secondary
Primary
Secondary
HMSA PPO/HMO/Fed
HMSA Quest
HMAA
UHA
Out of Pocket (Cash)
N/A
HMSA PPO/HMO/Fed
HMSA Quest
HMAA
UHA
Out of Pocket (Cash)
N/A
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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)
Medication Consultation / Monitoring
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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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Client Will Be:* This field is required.
Self
Child
Your Parent
Your Spouse
Other
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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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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
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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.
Madelyn Butac-Roeske, Psy.D. (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.
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Welcome to the Mililani Psychology Group