Sundial Mind Care, LLC | SimplePractice

Sundial Mind Care, LLC Send Message

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

State

Select the state you live in

Client Preferences

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

Reason for care

Are you currently located in Michigan, and you will be physically in Michigan during your telehealth appointments?

What brings you in today? (check all that apply)

Please note: Sundial Mind Care currently does not prescribe stimulant medications. If you are seeking stimulant treatment, we may not be the best fit for your needs.

Depression Mood Concerns Sleep Concerns Women's mental health Medication management ADHD evaluation ADHD (non stimulant treatment) Anxiety Other (please describe)

What is your age?

Under 12 12-17 18+

Are you currently experiencing thoughts of harming yourself or someone else, or are you in another mental health emergency?

if "yes" please call 911 or go the nearest emergency department, or contact 988

yes no

Do you understand that Sundial Mind Care is currently a cash-pay practice and does not bill insurance?

We do accept HSA cards

yes no

Please list any current psychiatric medications and the name of the provider who prescribes them.

(optional)

Are you seeking evaluation or treatment that requires a controlled substance medication (such as stimulant medications for ADHD or benzodiazepines for anxiety)?

At this time, Sundial Mind Care does not prescribe controlled substances. If your primary goal is to obtain or continue a controlled substance prescription, we may not be the best fit for your needs. If you are interested in a comprehensive psychiatric evaluation or discussing non-controlled treatment options, you are welcome to schedule an appointment.

yes no I'm not sure

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.