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Appointment Inquiry

So we can be fully prepared to help you, please complete this form. Feel free to stop and continue later. Should you have any questions, please contact our admin team at (314) 561-9757.

Step 1 of 4

25%

Will this appointment be for you or are you making a referral for someone else?(Required)

Myself

A minor child under my care

An adult under my care

I am making a referral for someone

Email(Required)

How did you hear about us?(Required)

Client Information

Please answer the questions below in regards to the client that will be seen at The Center for Mindfulness & CBT. Our Client Care Coordinator will be in touch very soon to talk to you more about scheduling your first appointment.

Name(Required)

Please enter the name of the person receiving treatment.

First Last

Preferred Pronouns(Required)

Please enter the preferred pronouns for the person seeking treatment.

Name(Required)

Please enter the name of the parent, guardian or referrer.

First Last

Parent or Guardian Date of Birth(Required)

Pelase enter the date of birth for the parent or guardian of the minor child seeking services.

Custody(Required)

Married (no parenting plan)

Divorced, separated, single, GAL, or legal parenting plan in place

Court involved

If parents are divorced and both have authority to authorize medical services, consent must be obtained from both parents.

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please enter the address for the person seeking treatment.

Date of Birth(Required)

Please enter the date of birth for the person seeking care.

Gender(Required)

Male

Female

Non-Binary

Other

Please enter the gender of the person seeking care.

Age(Required)

Child (3-12 years old)

Teen (13-17 years old)

Adult (18+ years old)

Please select the age range for the person seeking care.

Phone(Required)

Please enter the phone number of the person we should contact to set up the appointment.

What is the best time(s) of day to contact you for scheduling?

Morning

Afternoon

May we send you emails?(Required)

Yes

No

Referral source's name

First Last

What type of organization are you referring from?

A Physician's Office

A School or Educational Institution

Court or Social Services (DCBS)

A Hospital

Psychiatric Care

Inpatient Facility

Other Outpatient Facility

Referral source email

Please enter the email address for the person or organization making the referral.

Referral source fax number

Please enter the fax number for the person or organization making this referral.

Referral source phone number

Please enter the phone number for the person or organization making this referral.

What is Referral Source's preferred method of contact?

Email

Fax

Phone

How does the person making this referral prefer to be contacted?

What type of insurance would you like to use?(Required)

I have insurance but am willing to self-pay if needed for the best fit or soonest availability

I do not have insurance and plan to self-pay

Aetna

Anthem BCBS

Cigna

Medicare

United Healthcare/UMR

If you’d like to use insurance, what is your Member ID?

If you’d like to use insurance, what is your Group Number?

Name and Date of Birth of Insurance Policy Holder

Insurance Card Front

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

Please upload an image of the front of your insurance card.

Insurance Card Back

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

Please upload an image of the back of your insurance card.

What service(s) are you seeking?(Required)

Individual Counseling / Cognitive Behavioral Therapy (CBT)

Family Counseling

Couples or Marriage Counseling

Group Therapy

Mindfulness Course

Psychological Testing

Other

What are the primary concern(s) that you are seeking services for?(Required)

Anxiety

Obsessive Compulsive Disorder (OCD)

Body-Focused Repetitive Disorder (BFRB) like skin picking or hair pulling

Depression

Eating Disorder

Relationship Concerns

Life Transition

Traumatic Experience

Grief

ADHD

Behavioral Concerns

Autism

Bipolar Disorder

Substance Abuse

Other

If you are interested in seeing a specific provider, please let us know who you'd like to see, and we will do our best to accommodate the request if that provider has availability.

Is there anything else we should know before scheduling your first appointment?

contact

Contact

info@mindfulstl.com
P (314) 561-9757 F (314) 561-9050

Address

967 Gardenview Office Parkway
Creve Coeur, MO 63141

Hours

Monday – Friday
9:00am-5:00pm

“My goal is to help my patients break through barriers that keep them from reaching their full potential and live a happier life.”

― Dr. Laura Chackes ―

We are a leading mental health and wellness center in the St. Louis area providing innovative, evidence-based treatment to all people regardless of age, gender identity or expression, race, religion, sexual orientation, or ability level.

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