Sprout Midwest Wellness P.L.L.C

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Date of birth

State

Select the state you live in

Reason for care

What brings you to therapy at this time?

Depression, anxiety, desire for healing childhood wounds, self exploration, etc. What would you like your therapist to know?

Have you seen a mental health professional before?

If yes, please include a brief history of services (provider/agency, how long ago, reason for services at the time, etc.)

Billing & Payment

How are you hoping to pay for services?

Regardless of whether you utilize insurance to cover services or not, what insurance do you have?

Blue Cross Blue Shield of MN, Medicare, United Healthcare, PrimeWest, etc.

Client Preferences

Is there anything additional that you'd like the therapist to know at this time?

Limited to 600 characters

Do you consent to the use of AI in the delivery of your care?

Your clinician may use AI tools (such as using AI to generate an intake summary) to help support your care. Your information is protected under HIPAA and anything generated by AI is always reviewed by your clinician. AI does not make decisions about your care. You can withdraw this consent at any time by contacting your provider without it impacting the care you receive.

Yes No

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.