Appointments Request an Appointment Thank you for contacting us!If this is an emergency, please dial 911 or go to your nearest emergency facility. For urgent requests, please call our clinic directly at 651-647-1900 during regular office hours.Name First Last PhoneEmail What type of appointment is this?*New AppointmentFollow Up AppointmentReferent NameReferent OrganizationEntira Family ClinicHealth PartnersSouthdale PediatricsMetro PediatricsAllinaBHPOTHEROther Referent OrganizationReferent Email AddressPreferred type of sessionFace-to-FaceTelemedicine (Virtual)Most Convenient LocationBurnsvilleLake ElmoSaint Louis ParkSaint PaulRochesterWhat health issues are you experiencing?Which clinician would you prefer to see?First Available ClinicianSusan Banal, MSW, LICSWBrittany "Brit" Barkholtz, MSW, LICSWStephanie Becker, MSW, LGSWAlisha Beyer MA, LMFTDavid Brings, Ph.D, LPRachel Cain, MSW, LICSWJill Carlson, MA, LPCCKristy Costello, MS, LPCCTemitope (Temi) Dawodu DNP, FNP-BCMary Jo Faustgen, MA, LMFTColleen "Kelley" Garry Marschall, MA, LPCCJennifer Herman, MSW, LMFT, LICSW, QDDPDietrah C. Hiatt, MSW, LICSWSuzan Hurlbut, MA, LPAnnette Jacob, MSW, LICSWMolly Kehr, MA, LMFTMarcus Kuboy, MSW, LGSWAnne Kunesh Carney, MA, LMFTCatherine Molenaar, MANicole Munger, MSW, LICSWLinda Oakes, MA, Ph D, LPMarilyn Olson, MA, LPLisa Perlock, MA, LPCCRebecca Pihl, MSW, LICSWJack Quesnell, MSW, LICSW, LMFTPamela "Pam" Schinigoi, MSW, LGSWKathy Schliesman, MA, LMFTKathryn Weise, MA, LMFTAlison Whiteaker, MA, LAMFTDoug Petrie, MA, LPCC, CNT, RPTHow did you hear about us?Select Referral TypeBehavioral Healthcare Providers (BHP)Catholic Therapist.comClergyEmployee AssistanceEmployerFamily Doctor/ClinicEntira Family ClinicFirst Call for HelpFriend/FamilyHospitalHealth Partners ClinicsInsurancePrevious ClientProbation OfficeTherapist/PsychiatristWebsiteYellow PagesOtherCommentsNew Clients OnlyPlease provide the additional information below.Client's Date of BirthClient's Insurance CompanyPolicy Holder's Employer NameInsurance Member ID #Insurance Group #Policy Holder Name & Policy Holders Date of Birth (if different than client)Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Medical records can be faxed to 651-342-8023Health Care Professionals: A release of information must be attached. This iframe contains the logic required to handle Ajax powered Gravity Forms.
