GET STARTED

Take the first step by completing the

Preliminary Survey Assessment Form.

Getting started with medication management and counseling has never been easier.

Submit our 100% online preliminary assessment form to help us determine if our services are the right fit for you.

If you qualify, we’ll connect you with a provider and create a personalized treatment plan tailored to your needs and goals.

Let's start off by covering some basic information:

First Name *

Last Name Initial *

What is your age? *

Pls select your sex : *

How do you hear about us? *

What is your email address? *

What is your phone number? *

I agree to By checking this box, you agree to allow us to contact you using the phone number provided. We may use this number to send you updates on our latest news, events, and other relevant information via text message or phone call.terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

What County/City and State do you reside in? *

Privacy Policy | Terms of Service

What types of services are you interested in?

Medication Management

Minor Non-urgent Care (Cash Pay Only)

Telehealth Services

How do you plan to cover your sessions? *

What's is the name of your insurance provider?

What are your main objectives or areas you'd like to address through our services? *

What are your preferred times for appointments?

Are you interested in Telehealth (virtual) sessions? *

Yes

No

I'm not sure yet

Is there any other general information you'd like to share with us?

Please upload a copy of your driver’s license.

Please upload a copy of your insurance card.

By checking this box, I acknowledge that the information provided is accurate to the best of my knowledge. In addition, I consent to being contacted by A Healthy Mind for scheduling and further assessment. 6dht *

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