SWI Online Appt Request

Sexual Wellness Institute Appointment Request Form

Note: If you are experiencing a medical emergency please dial 911 to contact local emergency response personnel.

Please be assured that this online appointment request is secured and that information entered and submitted is strictly confidential.

You may also contact us by phone.
Twin Cities area: (651) 401-5010

Attention: If you are not the intended client, please be sure to fill this form out with the appropriate client information.

How did you hear about us?	*
New or returning client?	*	New Client Returning Client
Did you have a particular therapist in mind?		Amanda Sasek, MS LMFT Katie Schober-Ordoñez, MS LPC I'm unsure at this time
Please list reason for visit or symptoms for visit.

CLIENT INFORMATION
Client First Name:	*
Client Last Name:	*
Client Birthdate (mm/dd/yyyy):	*
Client Gender:	*	Male Female Other
Do you identify as transgender?		Yes No
If you identify as transgender, what are your preferred pronouns?
Address:	*
City, State:	*
Zip:	*
Phone Number (include area code):	*

CONTACT INFORMATION
You will be contacted by our scheduling coordinator to review additional medical and financial information, including insurance coverage, before an appointment for a consultation is offered. Please provide contact information below.
Scheduling Contact Person:	*
Best Phone Number to Call:	*
Best Time to Call:
May we leave a message?	*	Yes No
Alternative Contact Phone Number:
Best Time to Call:
May we leave a message?		Yes No
Email Address:	*
Is it okay to email you at this address about scheduling?	*	Yes No
If you would like to provide additional information to the scheduling coordinator, please type it here:
Security Code	*