Our Services
Request Services
About Us
Back
Outpatient Mental Health Counseling
Comprehensive Community Services (CCS)
First Responders/Critical Incident Stress Management
Back
Request Outpatient Mental Health Counseling
Request Comprehensive Community Services (CCS)
Request Brainspotting
Back
Our Mission
Our Team
Insurances Accepted
Resources
Careers
Our Services
Outpatient Mental Health Counseling
Comprehensive Community Services (CCS)
First Responders/Critical Incident Stress Management
Request Services
Request Outpatient Mental Health Counseling
Request Comprehensive Community Services (CCS)
Request Brainspotting
About Us
Our Mission
Our Team
Insurances Accepted
Resources
Careers
Request Brainspotting
Client Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Age in Years
*
Gender
*
Male
Female
Transgender Male to Female
Transgender Female to Male
Non-binary
Intersex
Prefer not to answer
Patient Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact Person's Name
*
Emergency Contact Person's Information
*
Payment Option
*
Employee Assistance Program (EAP)
Insurance
Private Pay
Other
Name of Health Insurance Company
Are you a current, former or future First Responder?
*
Yes
No
Type of First Responder (if applicable)
EMS/EMT
Firefighter
Law Enforcement
Other
What brings you in for Brainspotting?
*
What are your goals for Brainspotting?
*
Please include any other information you would like to share.
What is your appointment location preference?
*
Waunakee and Tomah in-person waiting lists are 6-12 months or longer. Consider also selecting virtual to lessen your wait time.
Check all that apply.
Reedsburg Office
Tomah Office
Waunakee Office
Virtual
How did you hear about Brainspotting with us?
Friend or Co-worker
Google
Other Search Engine (Bing, Yahoo, etc.)
Facebook
LinkedIn
Trailways Counseling Staff Member
Other Counseling Service
Thank you! You have been added to our waiting list.
