Appointment Request Form

First name

Last name

Confirm your e-mail

Telephone #

Date of Birth

Month

Day

Year

Type of Payment

Private Pay

Health Insurance

Not Sure

For Private pay we provide a sliding scaleIf you choose private pay, a sliding-scale option is available to help accommodate different financial situations..

Healthcare Insurance

Insurance Member ID

Is there something you would like us to know? / Is there a question we could answer?

By submitting this form:

You consent to the processing of your sensitive personal information, including any protected health information (PHI) you provide.
You consent to be contacted by Thriving Mind Solutions, LLC. You may receive a phone call from a 956 or 787 area code. You may also receive follow-up communication by email and/or text message.

We aim to respond within 24–48 hours. If this is an emergency or an urgent matter, please contact 911 or 988 immediately.