LynLake Psychotherapy & Wellness
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Legal Name of Client*
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What is the parent/guardian first and last name, and DOB?
Preferred method(s) of contact*
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Address*
Email*
Please note that an email must be provided in order to submit this form, and you will receive a confirmation / receipt email upon submission.
Are you a current client of LynLake Centers for WellBeing?*
In a few sentences please explain what prompted you to reach out for services (i.e. goals for care, concerning symptoms, modalities you may be interested in...) At this time LynLake is not providing testing services.
Were you referred to work with a specific provider(s) at LynLake?
Do you have a preference for a specific gender in a medication provider?
Do you need an interpreter?
Do you prefer a provider who specializes in prenatal care?
Do you take any of the following controlled substances:
If you are currently not on any medications, are you looking to be prescribed any controlled substances (such as stimulants for ADHD) or Benzodiazepine for your diagnosis?
What type of insurance is this?*
Do you have secondary insurance?*
What type of insurance is this?*
Are you enrolled in Medicare Part B?*
*Medicare Part B coverage is generally for those who are 65 and over, or for those with disabilities.*
Please upload your Insurance Card(s) and Government-Issued ID here:*
Uploading the following item can help expedite the intake process: Government-Issued ID: front of card needed. Insurance: front and back of card needed.
Please upload your government-issued ID (front only).
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Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
    Please upload your Primary Insurance Card (front + back).
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    Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
      Please upload your Secondary Insurance Card (front + back)
      Drop files here or
      Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
        Preferred Provider(s)
        If desired, please list the name(s) of the LynLake provider(s) who you prefer to work with.
        Please note that listing the provider name(s) here does not guarantee the provider(s) will be able to work with you at this time.
        Click [Add] to add additional lines.
        Please leave this blank if you do not wish to note a preference.
        Consent for Online Submission & Review*
        I understand that by submitting this online form my information will be sent via secure email to the LynLake Referrals Specialist Team. The Referrals Specialists will review my information and attempt to match me with a provider within 5-7 business days. My personal/demographic information, presenting concerns, and general appointment/provider request will otherwise be treated as confidential and private. I understand I can reach out to referrals@therapy-mn.com with questions.
        This field is for validation purposes and should be left unchanged.

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        • Contact Us
        • Client Portal
        • RX Refills
        • Billing
        • About Us
          • Our Practice
          • Our Approach
          • Our Team
          • Our Locations
        • For Professionals
          • Careers at LynLake
          • Upcoming Events
          • Professional Development
        • Therapy & Counseling
          • Individual Adult Therapy (18+)
          • Individual Child Therapy (<18)
          • Relationship, Couples & Marriage Therapy
          • Family Therapy
          • Group Therapy
          • College Student Services
        • Additional Services
          • Nutrition Services
          • Medication Management
          • Acupuncture
          • Wellness Services
          • Immigration Psychological Assessments
        LynLake Centers For Well Being

        Email: info@therapy-mn.com

        Phone: 612-979-2276

        Fax: 651-925-0427

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