Contact uslaura@numapsychotherapy.com tele: (612) 293-8758fax: (612) 446-5770708 N 1st St, Suite 234Minneapolis, MN 55401 Client Inquiries Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * For age and insurance verification purposes MM DD YYYY Preferred Setting * No preference In office Telehealth Preferred Provider(s) Any with availability/No preference Krista Jorgenson Laura Hagen Becca Darnell Nick Pranke Rebecca Enders Emily Steidel Jamie Halvorson Esmeralda Flores Brendan Sheehan Mitch Fuchs Carly Spotts-Falzone Awele Eneanya Marwa Ibrahim Jessi Grad Megan Creasey Quinnyana Houston Sara Elmekkawy Nic Parsons Payment * Please select the name of your insurance carrier. Select "Private pay" if you won't be using insurance. Select one Private pay Aetna America's PPO BCBS Cigna HealthPartners HealthEZ Hennepin Health Medical Assistance (MA) UCare PrimeWest South Country Health Alliance Other (please specify in message below) Do you have more than one insurance plan? * Yes No If yes: Please select the other insurance provider Aetna America's PPO BCBS Cigna HealthEZ HealthPartners Hennepin Health Medical Assistance (MA) UCare Out-of-Network (e.g. United/UBH/UMR, Medica) Insurance ID# (optional) If you don't currently have access to your insurance card, enter your member ID# Message * Please provide a brief summary (to the extent you're comfortable) about what you're looking to address in therapy and comment on your scheduling needs/preferences. Thank you! Please allow 2-3 business days for us to process and respond to your message.If this is an emergency, please contact 911.Additional crisis resources: National Suicide & Crisis Lifeline: 988Hennepin County Crisis (COPE): 612- 596-1223
