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 AppointmentDoctor's ReferralMost Convenient LocationSelect LocationBurnsvilleLake ElmoSt. Louis ParkSt. PaulWe will accommodate this if at all possible.What health issues are you experiencing? Which clinician would you prefer to see?First Available ClinicianSusan Banal, MSW, LICSWJason Becker, MA, LMFTInez Bersie-Mize , MFCS, LMFTDavid Brings , Ph.D, LPShanna Buhr, MA, LPCCJill Carlson, MA, LPCCJere Chapman , M.A., LPBarbara Cloutier , MA, LPKristy Costello, MS, LPCCNichelle Dillon, MSW, LICSWDorothy Elion, MS, LMFTMary Jo Faustgen , MA, LMFTRebecca Fraenkel , MA, LP, LICSWColleen "Kelley" Garry Marschall , MA, LPCCJennifer Herman , MSW, LMFT, LICSW, QDDPDietrah C. Haitt , MSW, LICSWSuzan Hurlbut , MA, LPAnnette Jacob , MSW, LICSWGlenda Janzen , MSW, LICSWMolly Kehr , MA, LMFTAnne Kunesh Carney , MA, LMFTCatherine Mollner , MA, LP, SEPNicole Munger, MSW, LICSWLinda Oakes, MA, Ph D, LPMarilyn Olson , MA, LPLisa Perlock, MA, LPCCJack Quesnell , MSW, LICSW, LMFTPaul Quie , MA,LMFTAndrea Robertson , MSW, LICSWMichele Sullivan , MA, LICSW, LMFTFarren Swanson, MA, LMFTMelissa Urbanek , MA, LMFTLinda Verbeck , MSW, LICSWKathryn Weise, MA, LAMFTRita Younger, MSW, LICSW, LMFTHow 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 PagesOtherComments New 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Medical records can be faxed to 651-342-8023Health Care Professionals: A release of information must be attached.
