Telehealth

More to come soon.

Name*
Date of Birth*
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Age*
Phone*
Email*
Health Insurance*
How did you hear about us?*
What brings you to Prairie Wellness?*
Please choose all that apply.
Therapist*
If the clinician you requested is not available, would you be open to a referral to one of our other therapists?*
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What days are you available for appointments? Please check all that apply.*
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- Wednesday
- Monday
- Thursday
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What times of day are you available? Please check all that apply.*
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- 2 PM - 3 PM
- 8 AM - 9 AM
- 3 PM - 4 PM
- 9 AM - 10 AM
- 4 PM - 5 PM
- 10 AM - 11 AM
- 5 PM - 6 PM
- 11 AM - 12 PM
- 6 PM - 7 PM
- 12 PM - 1 PM
- 7 PM - 8 PM
- 1 PM - 2 PM
If you were referred to Prairie Wellness, please tell us who it was.
Message
Electronic Security*
Email is not a 100% secure medium. Understanding its security limitations, I opt to use email as a means of communication.
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3209 Ingersoll Avenue, Suite 100, Des Moines, IA 50312 | 515.207.1705 | info@prairiewellness.com