Individual Counseling Service FormAdmin2022-05-26T13:52:34+00:00 First Name *Last Name *Preferred NamePronounsSelectHe/HimShe/HerThey/ThemSexSelectMaleFemaleOtherPhone Number *Mobile Phone NumberEmail *Street Address *Street Address Line 2 *City *State/Province *ZIP / Postal Code *Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweDate *Please upload a photo of the front and back of your driver's license or ID. *Choose FileNo file chosenDelete uploaded fileIs this person under the age of 18? *SelectYesNoAre the parents/guardians of this person divorced or separated? *YesNoParent/Guardian 1 Name *Parent/Guardian 1 Email *Parent/Guardian 1 Phone *Parent/Guardian 2 Name *Parent/Guardian 2 Email *Parent/Guardian 2 Phone *This is for maternal mental healthThere are currently divorce or custody issues/concernsWhat days/times work best? *Preferred Office Location *SelectBloomingtonBrainerd LakesBurnsvilleChaskaCoon RapidsEdinaGrand RapidsMendota HeightsMinneapolisMoorheadRochesterSt. PaulWinonaWoodburyAnyIf an immediate opening is available via telehealth at a location other than your preferred location, are you open to considering this option under the assumption you would continue seeing your provider virtually?YesNoInsurance Company * Before KESMA Flame Lily can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #Group Number *ID Number *Who is the policy holder for your insurance plan?SelfRelativePlease upload photos of the front and back of your insurance card.Choose FileNo file chosenDelete uploaded fileDo you have a supplemental insurance plan?SelectYesNoTherapist Gender Preference *SelectMaleFemaleNO PreferencePrevious/Current Diagnosis (if applicable)Are you a current or past KESMA Flame Lily client?SelectYesNoHow do you prefer we contact you? *PhoneEmailOtherWould you also like to schedule a Medication Management appointment at this time? *YesNoPlease provide a brief summary describing your goals in therapy or the type of support you are seeking: *How many Intake Assessments have you had in the current calendar year? *Our new program, KESMA Flame Lily, is an 8 week program for clients 18 + who have previously been in control of their mental health but are having trouble managing their stress recently. Over the course of 8 weeks, clients learn skills to help them cope with everyday stress and anxiety. You can learn more about KESMA Flame Lily by visiting www.flamelilytherapies.com. Are you interested in exploring whether KESMA Flame Lily is the right fit for you?YesNoAny additional information to help find a good match for a practitioner please write below:As soon as we receive a referral, KESMA Flame Lily staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination. How did you hear about us? *Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)OtherSend Message First Name *Last Name *Preferred NamePronounsSelectHe/HimShe/HerThey/ThemSexSelectMaleFemaleOtherPhone Number *Mobile Phone NumberEmail *Street Address *Street Address Line 2 *City *State/Province *ZIP / Postal Code *Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemen Arab Rep.Yemen DemocraticZambiaZimbabweDate *Please upload a photo of the front and back of your driver's license or ID. *Choose FileNo file chosenDelete uploaded fileIs this person under the age of 18? *SelectYesNoAre the parents/guardians of this person divorced or separated? *YesNoParent/Guardian 1 Name *Parent/Guardian 1 Email *Parent/Guardian 1 Phone *Parent/Guardian 2 Name *Parent/Guardian 2 Email *Parent/Guardian 2 Phone *This is for maternal mental healthThere are currently divorce or custody issues/concernsWhat days/times work best? *Preferred Office Location *SelectBloomingtonBrainerd LakesBurnsvilleChaskaCoon RapidsEdinaGrand RapidsMendota HeightsMinneapolisMoorheadRochesterSt. PaulWinonaWoodburyAnyIf an immediate opening is available via telehealth at a location other than your preferred location, are you open to considering this option under the assumption you would continue seeing your provider virtually?YesNoInsurance Company * Before KESMA Flame Lily can begin providing services to any client, we MUST have the insurance carrier, member ID # and group number as it appears on their member ID card. For example, if a client has PMAP coverage, we will need the specific PMAP plan information (insurance provider name, member ID and group #), before we can schedule an intake. If a client has straight Medical Assistance, we will just need their MA/PMI #Group Number *ID Number *Who is the policy holder for your insurance plan?SelfRelativePlease upload photos of the front and back of your insurance card.Choose FileNo file chosenDelete uploaded fileDo you have a supplemental insurance plan?SelectYesNoTherapist Gender Preference *SelectMaleFemaleNO PreferencePrevious/Current Diagnosis (if applicable)Are you a current or past KESMA Flame Lily client?SelectYesNoHow do you prefer we contact you? *PhoneEmailOtherWould you also like to schedule a Medication Management appointment at this time? *YesNoPlease provide a brief summary describing your goals in therapy or the type of support you are seeking: *How many Intake Assessments have you had in the current calendar year? *Our new program, KESMA Flame Lily, is an 8 week program for clients 18 + who have previously been in control of their mental health but are having trouble managing their stress recently. Over the course of 8 weeks, clients learn skills to help them cope with everyday stress and anxiety. You can learn more about KESMA Flame Lily by visiting www.flamelilytherapies.com. Are you interested in exploring whether KESMA Flame Lily is the right fit for you?YesNoAny additional information to help find a good match for a practitioner please write below:As soon as we receive a referral, KESMA Flame Lily staff will begin processing and verifying insurance coverage. If a client has "inactive" insurance, we will not be able to schedule an intake until we have confirmed that insurance is active. If a client has a PMAP plan, and we do not have the plan name, member ID and group numbers, we will not be able to schedule an intake. We will work with you, the referral source, to work on ensuring that coverage is in place. Thank you for working with us. We appreciate the support and assistance in coordination. How did you hear about us? *Internet Search (Google)Friend or Family MemberAnother Provider (ie. Doctor, case manager)An online advertisement (Facebook/YouTube)Other Media (i.e. radio or TV)NewsletterAt a Community Event (ie. resource fair, presentation)OtherSend Message