Inquiry Form

Counseling & Specialty Services

Thank you for your interest in MindSource Center’s Counseling and Autism Assessment services. We look forward to serving you.

Please complete the following information so that we know best how to assist you. You can expect a response from our team shortly.

Counseling & Assessment Services Request

First Name:(Required)

Last Name:(Required)

Street Address:(Required)

City:(Required)

ZIP / Postal Code:(Required)

Phone Number:

Email Address:(Required)

Birthdate:

Are you requesting services for yourself or for someone else?(Required)

Myself

Someone Else

Your Name (if requesting for someone else):

Your Relationship to the Patient (if requesting for someone else):

Briefly describe the services you are requesting:

Hours of availability for therapy services:

Morning 8am-12pm

Afternoon 12-3pm

Evening 3-6pm

Available Anytime

I am interested in the following services: (select all that apply)

Mental Health Counseling

Parent Training

Neuropsychological Assessment or Autism Diagnosis

Social Groups

Summer Camp

Applied Behavior Analysis (ABA)

Professional Consultation

Speech Therapy

Art Therapy

Other

Name of insurance plan: (e.g., Premera, Regence Blue Cross/Blue Shield, Aetna, private pay)*

Whom may we thank for referring you?

Trusted Autism Experts

Serving South King County Families since 2003

Request Services

Mindsource Center • 27023 164th Ave SE • Covington, WA 98042
We serve the cities of Kent, Renton, Auburn, Maple Valley, Covington, Federal Way, and others.
(253) 639-7146 phone / (253) 639-7145 fax / help@mindsourcecenter.com