New and Prospective Clients

If you are interested in learning more about CALM or would like to schedule an appointment, please complete the fields below for yourself or your child to have one of CALM’s office staff reach out to you.

Client's Legal Name

First Name

Last Name

Preferred Name

Preferred Pronouns

Date of Birth

MM

DD

YYYY

Parent's Name (If Client Is a minor)

First Name

Last Name

Parent's Name (If Client Is a minor)

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Insurance

Will you be using a BC/BS plan OR will be paying out of pocket for our services? CALM will need pictures of the front and back of all your insurance cards (if you have more than one) in order to best determine coverage.

Appointment Type

Additional Information

Any additional information you would like to share with CALM?

New and Prospective Clients

Clinic for Attention, Learning, and Memory (CALM)

Claire@calm.us

Mercey@calm.us

Phone: (612)872-2343 (Ext 2)

Fax:(612)870-4279

New and Prospective Clients

Clinic for Attention, Learning, and Memory (CALM)

Claire@calm.us

Mercey@calm.us

Phone: (612)872-2343 (Ext 2)

Fax:(612)870-4279

Address

Hours