INTEREST FORM

INTEREST FORM
Thank you for your interest in Mindful Counseling.

In order to established as a client, Mindful Counseling will need some information about the individual seeking counseling. Please complete and submit this INTEREST Jotform in its entirety.

Once received our office will contact you to discuss your options.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Chosen/ Preferred Name

First NameLast Name
Pronouns
Age*
Date of Birth*

MonthDayYear
Date
Guardian's Name (if applicable)

First NameLast Name
Phone #*

Area CodePhone Number
Email *
By providing your email address you are consenting to be contacted at this email address by our staff. * Email is not considered a secure medium and therefore, confidentiality cannot be assured. Please use discretion when emailing information that is sensitive in nature.
For whom are you seeking counseling services?*

MyselfOther
If OTHER please indicate the name, DOB and your relation to the individual for whom you are seeking counseling.
IF OTHER PLEASE NOTE: Mindful Counseling does not accept 3 Party Referrals. Potential clients must be willing to attend WEEKLY appointments and engage in the process of establishing as a new client by completing this form and talking directly with our staff about the services they are requesting and Mindful Counseling's billing options.
What type of counseling services are you seeking?*

IndividualFamilyCouples
How did you learn about Mindful Counseling? *

Couples or Family Counseling
If you are requesting Couples or Family counseling, please consider that all individuals must be willing to participate in weekly counseling.*

I attest that ALL parties are willing to participate in weekly counseling.
Please list the names of each Couples or Family Counseling participant and their relation to you.*

If you are having current thoughts of harming yourself please contact the NM Crisis Line https://nmcrisisline.com/ at 855-662-7474 available 24/7 or The National Suicide Prevention Lifeline https://suicidepreventionlifeline.org/ at 800-273-8255.

So that we can match you with a provider that is the best fit for you, please provide details specific to why you are seeking counseling and what you are wanting help with. *
Please Select Your Location Preference*

I would prefer a Telehealth Appointment (online, involving a live audio/video connection **see requirements below)I would prefer an In-Person Appointment at Mindful Counseling's North East Office (4004 Carlisle Blvd NE, near Montgomery)I would prefer an In-Person Appointment at Mindful Counseling's Westside Office (4619 Greene St NW near Golf Course and Irving).I'm flexible (open to Telehealth and I have no location preference).
**TELEHEALTH REQUIREMENTS - The NM Regulations and Licensing Department requires individuals receiving telehealth services from Mindful Counseling to physically be in the state of New Mexico during their telehealth sessions. To assure privacy, a secure and private Internet connection should be utilized and all participants should have both auditory and physical privacy while speaking with their provider during telehealth sessions.
What day(s) of the week and blocks of time(s) are you available to attend WEEKLY counseling appointments? **Please refer to our website for current appointment availability.*
Do you prefer a specific therapist?*

YesNo
If YES, who?
Payment Options:
A description of the two options Mindful Counseling offers, to include a list of the insurance companies our staff can bill, is located in the PAYMENT OPTIONS tab of our website, https://mindfulcounseling.org/payment-options.html
How would you like to pay?*

Private Pay: If you choose PP, the rate is $95 per session and your form is complete.Insurance: In order to bill your insurance, YOU WILL NEED TO CONTACT YOUR INSURANCE TO VERIFY YOUR POLICY'S CURRENT MENTAL HEALTH OFFICE AND MENTAL HEALTH TELEHEALTH BENEFITS. Missing or incorrect policy information indicated on your form will delay the process of securing an appointment and can result in compounding billing issues that may result in out of pocket expenses.

Mindful Counseling's billing department can sends claims to the insurance company's listed in the PAYMENT OPTIONS tab of our website.
Primary Insurance Company Name . *
In order to bill an insurance policy for the services Mindful Counseling provides, our staff is required to have a copy of the policy's insurance card on file. Please upload a photo of the front and back of Primary Insurance card below. *

Browse Files
Insurance Card Front Cancelof
Browse Files
Insurance Card Back Cancelof
Insurance ID #*
Group #*
If the client is not the policy holder, indicate the policy holder’s information:
Is the identified client the insurance policy holder?*

YesNo **If No, policy holder's information will be obtained.

Policy Holder Name*

First NameLast Name
Policy Holder Date of Birth*

MonthDayYear
Date
Relation to client*

Deductible amount (If IND and FAM deductible's apply, indicate both):*
A deductible is an amount you pay for covered health care services before your insurance plan starts to pay.
Deductible amount met, to date:*
When a policy's deductible is met, often times the client cost share drops.
What is your cost share after the deductible is met?*
What is the policy’s Out of Pocket Max?*
An Out of Pocket Max is the most a policy holder will have to pay, per year, for covered healthcare services.
Out of Pocket amount met, to date:*
Once a policy's annual Out of Pocket Max is met, until the policy renews, claims are covered at 100% with no client cost share.

Co-Pay Amount:*
What is the policy’s Out of Pocket Max?*
An Out of Pocket Max is the most a policy holder will have to pay, per year, for covered healthcare services.
Out of Pocket amount met, to date:*
Once a policy's annual Out of Pocket Max is met, until the policy renews, claims are covered at 100% with no client cost share.

Do you have a Health Savings (Flexible Spending) Account?*

NoYes

How does your HRA/Flex Spending account work?

I will submit Mindful Counseling's receipt to my HSA and request reimbursement.I manage my HSA funds with a credit/debit card.My HRA account will send payments directly to Mindful Counseling.Other

Do you have a secondary insurance?*

NoYes **If Yes, complete ALL the secondary policy’s information.

Mindful Counseling's billing department can sends claims to the insurance company's listed in the PAYMENT OPTIONS tab of our website.
Secondary Insurance Company Name*
In order to bill an insurance policy for the services Mindful Counseling provides, our staff is required to have a copy of the policy's insurance card on file. Please upload a photo of the front and back of Primary Insurance card below. *

Browse Files
Front of Insurance Card Cancelof
Browse Files
Back of Insurance Card Cancelof
Secondary Insurance ID #*
Secondary Insurance Group#*
Does this secondary insurance policy run on a calendar year?*

YesNo
If NO, what month is the renewal?
When insurance policy's renew annually, benefits and coverage can change.
Is the identified client the secondary insurance policy holder?*

YesNo **If No, policy holder's information will be obtained.

Secondary Policy Holder Name*

First NameLast Name
Secondary Policy Holder Date of Birth*

MonthDayYear
Date
Relation to Client *

Signature*

Clear
By checking this box I attest to Esigning this document
Should be Empty:

INTEREST FORM

Couples or Family Counseling

Payment Options: