Legal Name

Preferred Name

Pronouns

Email Address

Preferred Clinician
No PreferenceCJDenaJessicaLisaMariselaMeyaRoxanneSherri AnnTriciaVanessa

Preferred Session Modality
No PreferenceIn Person at Round Rock OfficeTele-HealthInstitutional or Care Facility

Reason For Seeking Therapy

How Did You Hear About Us?

Any Other Details (optional)

Client First Name

Client Last Name

Parent / Guardian name (For MINORS)

Preferred Phone Number
Please enter the phone number you prefer to use appointment reminders and notifications. (For MINORS, use parent / guardian)

Contact Email
Please enter the email you prefer to use for your new patient portal, appointment reminders, and notifications.

Client Date of Birth

Which insurance will you be utilizing? If you will be a private pay client, please indicate “Private Pay”

Type of Therapy
—IndividualCouplesFamily Group

Choose Your Location
—Round Rock / AustinHoustonGeorgetownSalado / KilleenTelehealth Appointment

What brings you to therapy?

Consent to Submit Information Digitally

Mesquite Psychotherapy and Consulting is HIPPA compliant and will not share any sensitive information or data with third-parties or non-HIPPA compliant systems. By agreeing to submit your information electronically, you agree that we can communicate with you via email regarding appointments but also opt-in to receive newsletters from Mesquite Psychotherapy and Consulting. If you prefer not to submit your information electronically at this time, please call our office at 512-284-7077 to set-up your appointment.
Do you accept?