Roswell Infusions LLC DBA Roswell MindCare

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

Is the client a minor?

(please note we only see ages 14+)

Yes No

Preferred Pronouns

she/her/hers, he/him/his, they/them/their, etc.

Administrative

Referral Source

How did you hear about us? Please specify if a person or provider.

Payment method

How do you plan to pay?

Billing & Payment

Insurance card upload

Upload a photo of your insurance card

Client Preferences

What times work best for you? (We can provide work and school verification letters)

Availability may be limited, but we’ll do our best to accommodate.

Morning Midday Afternoon

Preferred modality

We are located at 300 S Lea Ave in Roswell, NM. Telehealth is on a case-by-case basis.

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

What days work best for you? (Select all that apply)

Availability may be limited, but we’ll do our best to accommodate.

Monday Tuesday Wednesday Thursday

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.