Your Path to Better Mental Health Starts with

Mind Works

Your Journey

Connect with Mindworks

Address

11801 Pierce St, Suite 200, Riverside, CA 92505

Email

Support@mindworks
california.com

Phone

(909) 475-0137

(909) 487-1429

Health Information Form

Please complete all fields to help us serve you better

Your Wellness Starts Here

We provide compassionate and professional healthcare designed around your needs. Please fill out this patient form to help us understand your medical background better.
Your details ensure our medical team delivers personalized care tailored to your unique health goals.

Personal Information

First Name *

Last Name *

Email Address *

Date of Birth *

Home Address *

Phone Number *

Payment Information

Payment Option *

Health Questions

I have reviewed MindWorks services and I am aware of their private practice style and treatment paths. I am interested in *

Yes

I am aware that for licensing reasons in order to seek treatment with MindWorks , I must be a resident in the state of California *

Yes, I am a resident in the state of California

No, I am not a resident in the state of California

I have reviewed MindWorks's fee structure and billing practices outlined in the FAQs and I agree to pay the fees if I decide to book. *

Yes, I have reviewed the fees and I agree to pay them.

No, I have not reviewed the fees or am not able to pay them

Additional Information

Do you have any questions regarding fees or billing that were not answered on this site? If so, please ask them here. *

What problem are you dealing with that's led you to reach out for help? *

What are you hoping to get out of treatment? *