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Self-Pay Form

Please fill out this form as required to begin your sessions.

***Please let us know if you have any issues with the form! We can resend it, or you can send us your information via email.

First name

Last name

Phone

Please select the type of therapy you are seeking.

Check out our therapists here!

Which therapist will you see?

Please select your pronouns.

Do you prefer your sessions be conducted by phone or by video?

Is your address correct on your driver's license/ID? If not, please provide your current address.

Please select the issues you would like to address in therapy.

ADHD

Anxiety

Codependency

Couple Issues

Divorce

Life Coaching

Mood Disorders (Bipolar, Borderline Personality Disorder, etc)

School Issues

Self-Harming

Stress

Suicidal Ideation

Women's Issues

Please select the issues you would like to address in therapy

Anger Management

Coping Skills

Depression

Domestic Violence

Grief

Life Transitions

Peer Relationships

Self-Esteem

Social Anxiety

Spirituality

Substance Abuse

Trauma

Let us know what your top three issues are.

Please let us know what days and times work best for you! Please be specific as necessary.

Please upload the front of your driver's license/ID (For couples/families, it would be best if you uploaded yours together)

Upload File

Upload supported file (Max 15MB)

Please upload the back of your driver's license/ID (For couples/families, it would be best if you uploaded yours together)

Upload File

Upload supported file (Max 15MB)

The Mental Haven

A private practice operating with you in mind.

Hours of Operation

Mon-Thu: 9AM to 6PM

Friday: 9AM to 12PM

Sat-Sun: Closed

Therapists hours vary as they make their own schedule. Some therapists do see clients past 6p and on the weekend.

Contact Us

Gulfport, MS 39507

Montgomery, AL 36106

Murfreesboro, TN 37129

Support@MentalHaven.net