Champion State of Mind

ATTENTION: Due to COVID-19, a majority of insurance companies are now covering Telehealth therapy services. We are happy to assist you with the Telehealth process and will work directly with your insurance company.

Champion State of Mind is in-network with many major insurance companies. We also accept self-pay and sliding fee scale applications. Please visit HERE for more information.

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First Name

Last Name

Date of Birth

Phone Number

Preferred Appointment Location

Preferred Contact Method

Spoken Language

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The use of the Internet or this form for communication with Champion State of Mind does not establish a therapist-client relationship or guarantee an appointment. Confidential or time-sensitive information should not be sent through this form. By submitting the following information, you acknowledge and accept that such transmission of information will be sent via electronic means of communication which thereby confidentiality cannot be fully secured or guaranteed. Champion State of Mind follows HIPAA compliance regulations which limit the transmission of confidential information over an unsecured e-mail server.