Personalized Wellness Consultation Request Form

Wellness Consultation Referral & Consent Form

Please complete the following consent form to get scheduled. If we have availability during one of the times you listed, you will receive an email invite for your appointment. If we do not have availability, a member of the KESMA Flame Lily team will reach out to you by phone to find another time that works for you.

Personalized Wellness Consultations are held virtually with one of the therapists across KESMA Flame Lily’s numerous locations via Microsoft Teams.

KESMA Flame Lily has partnered with multiple employers to provide Personalized Wellness Consultations for their employees. This service is funded by the employer and is meant to encourage employees to do more for themselves & feel supported in doing so. While not everyone is ready for or seeking traditional therapy, there are many who are “just wanting to check in with someone”. Please complete the following consent form to get scheduled. If we have availability during one of the times you listed, you will receive an email invite for your appointment. If we do not have availability, a member of the KESMA Flame Lily team will reach out to you by phone to find another time that works for you. Personalized Wellness Consultations are held virtually with one of the therapists across KESMA Flame Lily’s numerous locations via Microsoft Teams.

Name

Date of Birth

Phone Number

Email Address

Employer

Please list 3-4 dates & times within the next week that you are available for a 50-60 minute Wellness Consultation. Please note: availability is typically limited to regular business hours (Mon-Fri 8am-5pm).Type here... **Your Wellness Consultation will be scheduled within one of these time frames & confirmation will be emailed to you. If there are no available appointments during the above dates & times, you will receive a phone call from KESMA Flame Lily staff to find another time that works for you.

Before engaging in a Wellness Consultation at KESMA Flame Lily please review and initial that you understand the following information.

I understand that I will be given a 50-60 minute Wellness Consultation from a practitioner at KESMA Flame Lily as part of a wellness initiative offered by my employer.

I understand that my employer will be notified that I have attended the Wellness Consultation and that this is the only information that will be provided to my employer.

I understand that my employer will NOT be notified about any personal information shared during the Wellness Consultation.

I understand that I will not be engaging in medically necessary or other therapeutic services and no part of the Wellness Consultation will be considered treatment of any medical or mental health disorder.

I understand that if I decide that I might benefit from ongoing services, KESMA Flame Lily will help me identify what those services might be and make referrals for further support at my request.

I will not hold KESMA Flame Lily liable for any outcomes that may result from engaging in a Wellness Consultation and if I have any questions regarding my Wellness Consultation I will talk to a member of the KESMA Flame Lily team.

I understand that the only documentation of the Wellness Consultation will be this consent form and will be stored in a protected file at KESMA Flame Lily, with access limited to the administrative & executive teams.

By signing this form below, I agree that I understand the preceding information outlined regarding engaging in a Wellness Consultation at KESMA Flame Lily LLC.

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Personalized Wellness Consultation Request Form

If you have any questions, please call our client specialists at 651.313.8080 between the hours of 8:30 am and 5:00 pm CST Monday through Friday. We can help you find the appropriate services and schedule your first appointment.

Before we get started, please have your insurance information and medical history.

Wellness Consultation Referral & Consent Form

Please indicate topics of interest for your Wellness Consultation:

How do you prefer we contact you? *

How did you hear about us? *