Contact us.

mendingrootstherapy@gmail.com
(507)-388-8874

1227 Caledonia Street
Mankato, MN 56001

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Intake Form

To request services please fill out this form and our office will contact you within a few days. It may take a few days to verify your insurance and we will email you the rest of the intake paperwork.

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Parent/Guardian Name and Number

(If applicable)

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email

Reason for Requesting Therapy

You can include provider preference

Insurance Company and Policy/Member Number or ID

Sex Assigned at Birth

This is only required for billing insurance. You can also include your gender/pronouns.

Contact us.

Intake Form

1227 Caledonia Street, Mankato, MN

mendingrootstherapy@gmail.com

Phone: 507-388-8874

Fax: 507-625-4807