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



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.