Client Portal - Artesian Spring Counseling

Appointment Request

Thank you for contacting Artesian Spring Counseling. Please fill out the information below to request your first appointment.

Personal Information:

First Name:*

Middle Name:

Last Name:*

Date of Birth:*

Gender of Legal Record:*

Male Female

Contact Information

E-mail:*

Phone:*

Address

Address type:		Street Address:

City:		State:

Zip code:

Provider:

Please explain the reason you are seeking help at this time.

Your Information is confidential. However, if you are uncomfortable fully describing your reasons for seeking services, please provide enough information so our staff can match you with the appropriate provider.

If this is a life threatening emergency, call 911.

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Appointment Request

Thank you for contacting Artesian Spring Counseling. Please fill out the information below to request your first appointment.

Personal Information

First Name:* Middle Name: Last Name:* Date of Birth:* Gender of Legal Record:* Male Female

Contact Information

E-mail:*

Phone

Type:*
Number:*

Address

Type:* Street Address: Line2: City: State:
Zip Code:

Provider:

Please explain the reason you are seeking help at this time:

Inspiring Hope, Nurturing Vitality, Empowering Change

Submit

Cancel

Clinic Address

3800 American Blvd 1500
Edina, 55431-4429

Billing Address

7500 Edinborough Way, 3105
Edina, MN 55435-5609

Clinic Phone No.

(763) 464-1168

Billing Phone No.

(763) 464-1168