*If you are in crisis or need immediate assistance, please call 988 or go to the nearest hospital ER*

First Name *

Last Name *

Phone *

Email *

Date of birth *

*Please note we are only taking adult (18+) clients at this time.

How did you hear about True North Therapy & Wellness? *

Referral Source

I'm a former client
Family/ Friend / Colleague
Healthcare Provider
Psychology Today
Search Engine
Insurance Referral Network
Other
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Health Insurance *

Insurance or Private Pay

Private Pay (not using any health insurance coverage)
Blue Cross / Blue Shield (Wellmark, out of state BC/BS, or Federal Employee Program FEP)
Health Partners - Unity Point
Health Partners (not Unity Point)
Aetna
Midland's Choice
United Healthcare
ClaimDoc
Iowa Total Care
Molina Healthcare
Wellpoint (formerly Amerigroup)
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*Please note we are unable to accept Medicare or any Medicare Advantage plan*

Insurance Member ID #

What brings you to therapy (chose all that apply)? *

Therapy Concerns

Anxiety
Depression
Trauma / PTSD
Binge or Emotional Eating
ADHD
Self-criticism / Lack of self-worth
Sleep Problems
Grief / Loss
Stress Management
Relationship Problems
Life Transition
Other*
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*Please note we are unable to treat the following: Anorexia, Bulimia, Psychosis / Psychotic Disorders, Substance Addiction

Which therapist would you like to see? *

Therapist Preference

Jessica
Nichole
Jackie
Not sure / would like recommendation
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If your preferred therapist is unavailable, would you like a referral to a different therapist at True North? *

Yes

Are you looking for in-person or virtual appointments? *

In Person or Virtual?

In-person
Virtual
Either is fine
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Virtual sessions are not appropriate for clients experiencing certain symptoms due to increased safety risks, including: suicidal thoughts, homicidal thoughts, hallucinations, recent suicide attempt or self harm, or recently physically assaulting others. Please choose which option below fits you best. *

Virtual Session Safety

I have NOT experienced any symptoms listed above in the past 2 WEEKS.
I HAVE experienced one or more of the symptoms listed above in the past 2 WEEKS. I am able and willing to proceed with IN-PERSON sessions in West Des Moines until safety issues can be further assessed and stabilized.
I HAVE experienced one or more of the symptoms listed above in the past 2 WEEKS, and am unable or unwilling to proceed with in-person sessions in West Des Moines.
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Licensing laws require clients to be physically located inside the state of Iowa during ALL virtual sessions. What city/town in Iowa do expect to be located in during your sessions? *

Our therapists generally schedule new clients weekly at the same day/time each week. Is this workable for you? *

Consistent Schedule Availability

Yes
No, my schedule varies week to week
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Scheduling Availability (Variable)

Days/times available for client scheduling varies by therapist (see each therapist's page for their schedule). Please indicate below what times you are available for appointments.

Monday Availability

Please choose all that apply

Anytime Monday
8am
9am
10am
11am
12am
1pm
3pm
4pm
5pm
6pm
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Tuesday Availability

Please choose all that apply

Anytime Tuesday
8am
9am
10am
11am
12pm
1pm
3pm
4pm
5pm
6pm
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Wednesday Availability

Please choose all that apply

Anytime Wednesday
8am
9am
10am
11am
12pm
1pm
3pm
4pm
5pm
6pm
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Thursday Availability

Please choose all that apply

Anytime Thursday
8am
9am
10am
11am
12pm
1pm
3pm
4pm
5pm
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Friday Availability

Please choose all that apply

Anytime Friday
9am
10am
11am
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Do you have any additional scheduling flexibility (other than marked above) if we are unable to accommodate the days/times requested? *

Schedule Flexibility

Yes - my schedule is flexible, I'd be able to meet any of the day/time options listed above
Yes - I have some additional flexibility
No - I would only be able to meet regularly at the times I indicated
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Anything else we should know to help get you started?

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