Request Appointment

If this is an emergency, please dial 911 or go to your nearest emergency facility.

Full Name (required)

Email Address (required)

Phone Number (required)

Parent/Guardian Name (if client is minor/vulnerable adult)

Best Time To Contact?

New Clients Only

Please provide additional information below

Date of Birth (MM/DD/YYYY)

Most Convenient Location

Which Provider Would You Prefer to See? (we will accommodate if at all possible)

How Did You Hear About Us?

Primary Insurance Company

Identification Number

Group Number

Policy Holder's Name and Date of Birth (if different than client)

Secondary Insurance Company (if applicable)

Identification Number

Group Number

Policy Holder's Name and Date of Birth (if different than client)

Medical Records can be faxed to: 507-235-6074

*Health Care Professionals, Human Services, and Probation: A release of information must be faxed as well.*