Request a New Appointment

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If you are in crisis and are unable to reach your therapist or the office, please contact the Crisis line: (808) 832-3100 (ACCESS Line) or Call 911
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Your Name* This field is required.
First Name
Last Name
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Contact phone number:* This field is required.
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Email
example@example.com
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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 requesting appointment is:* This field is required.
Yourself
Child
Parent
Spouse
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Client's Name and Date of Birth:* This field is required.
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Age of Child* This field is required.
4-11 Years
12-17 Years
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Name of School Attending and Grade
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For a minor, please confirm whether parents are together:* This field is required.
Parents 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 of Minor* 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.
Area Code
Phone Number
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2nd Parent of Minor* 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.
Area Code
Phone Number
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Referred By:
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Referred to:
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Has the client been referred for any of the following reasons:
AD/HD
Depressed Mood
Anxiety
Behavioral Issues
Suicidal Thoughts
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Reason for Appointment* This field is required.
Therapy
Psychological / Educational Testing
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Have you/they been tested before?* This field is required.
Yes
No
Maybe
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Date of Last Evaluation
Date
Year
Month
Day
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Online or In-Person Therapy* This field is required.Please check all that apply
In-Person Therapy
Online Therapy
Not Sure
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Therapy Type* This field is required.
Individual Therapy
Couples Therapy
Family Therapy
Family Therapy (Including a minor)
Parent Training
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Are services sought out for any accident, work, custodial, or legal-related issues?* This field is required.
Yes
No
Maybe
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Unfortunately, we are unable to provide services for accidents, work, custodial or legal-related issues at this time. Thank you for contacting us.
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Insurance Type:* This field is required.Mililani Psychology Group only accepts HMSA, HMSA Quest, HMAA & UHA as your PRIMARY carrier, otherwise, payment will need to be provided in cash.
HMSA PPO/HMO/Fed
HMSA Quest
HMAA
UHA
Medicare
None
Other
Primary
Secondary
Primary
Secondary
HMSA PPO/HMO/Fed
HMSA Quest
HMAA
UHA
Medicare
None
Other
HMSA PPO/HMO/Fed
HMSA Quest
HMAA
UHA
Medicare
None
Other
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Which of the following is acceptable for leaving messages:* This field is required.
Phone
Text
Email
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Available days of the week and times:* This field is required.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Mornings 7:00am - 12:00pm
Afternoons 12:00pm - 5:00pm
Evenings 5:00pm - 8:00pm
Mornings 7:00am - 12:00pm
Afternoons 12:00pm - 5:00pm
Evenings 5:00pm - 8:00pm
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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List specific days of the week and times if applicable:
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Brief description of concerns, additional comments or questions. Thank you!
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