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 Appointment Follow Up Appointment Referent Name Referent OrganizationSelect OneEntira Family ClinicHealth PartnersSouthdale PediatricsMetro PediatricsAllinaBHPOTHEROther Referent Organization Referent Email Address Preferred type of session Face-to-Face Telemedicine (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, LICSWAlisha Beyer MA, LMFTDavid Brings, Ph.D, LPRachel Cain, MSW, LICSWJill Carlson, MA, LPCCKristy Costello, MS, LPCCMary 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, LMFTNicole Munger, MSW, LICSWCatherine Molenaar, MALinda Oakes, MA, Ph D, LPMarilyn Olson, MA, LPLisa Perlock, MA, LPCCRebecca Pihl, MSW, LICSWPamela "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 Birth Client's Insurance Company Policy Holder's Employer Name Insurance 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 SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Medical records can be faxed to 651-342-8023Health Care Professionals: A release of information must be attached.Untitled
