Contact Us
Interest form for new clients
If you are interested in receiving mental health services or gender affirming medical care at Mangata Wellness, please complete the contact form below for us to review. We will do our best to find a fit among our therapists as appropriate. If we do not provide the needed service or do not have openings, we will respond to you with a list of community referrals.
By completing this form, you will be registering with our secure, HIPAA compliant Electronic Health Record service, Simple Practice. You will receive a followup email from Simple Practice with instructions to log into the health record system that will expire 24 hours after the email.
Disclaimer: Completing the New Client Interest Form does not establish a therapist-client relationship or guarantee services. This form is intended to gather preliminary information to determine potential service availability. Formal client status is only established after an initial consultation, mutual agreement on services, and the completion of all required intake documents. If you are experiencing a mental health emergency, please call 911 or seek immediate support from a crisis service provider.