top of page

Chat With Leo
About Leo
Emergency Help
Find A Therapist
What's Coming Next
Contact

Leo Mind Clinical Intake Form

Clinical Information :

Full Name*

Credentials (e.g., LPC, PhD, LCSW, MD)*

License Number and State*

Years of Experience*

Areas of Specialization (check all that apply)*

Anxiety

Depression

Trauma/PTSD

LGBTQ+ Affirming

Child/Adolescent Therapy

Couples/Marriage Therapy

Substance Abuse

Other

Practice Information:

Practice/Clinic Name (if applicable)

Office Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Website or Professional Profile Link (optional)

Client Information:

Do you currently accept new patients?*

Yes

Do you offer telehealth services?*

Yes

Insurance Accepted (if any)

Professional Bio:

(Short paragraph to appear on the LeoMind directory - 3-5 sentences about your approach and philosophy.)*

Verification:

Upload a copy of your valid professional license (PDF or photo) *

Upload proof of malpractice insurance (optional but preferred)

Consent:

I consent to have my information shared on LeoMind’s platform.

I affirm that all information provided is true and accurate to the best of my knowledge.

Signature*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date*

Quick Links

Contact Us

aaronleoquantitech@gmail.com

Email*

Leo is not a therapist. This platform is not for crisis situations.

Terms & Privacy Policy

bottom of page