Contact

1105 West Ironwood Drive, Coeur d'Alene, ID, USA
Our confidential Fax Number is 208-676-1009. We offer notary services by appointment, if you are in need of a notary please call our office to schedule.

+1-208-676-1003
mwcofcda@gmail.com
Monday - Thursday 9-5 Friday 10-4 For 2023: Our office is closed on Memorial Day, Independence Day, Labor Day, Thanksgiving Day, Christmas Eve, Christmas Day, New Years Eve, and New Years Day.

Name*

Phone*

Email address*

Date of Birth*

Date of Birth

Insurance Type*

Insurance ID Number*

Who were you referred by?*

Brief summary of your concerns*

History of substance use

Yes
No

History of physical abuse

Yes
No

History of sexual abuse

Yes
No

History of suicide attempts

Yes
No

Have you received a previous mental health diagnosis?

Yes
No

If so, what diagnosis was given?

Are you currently on any medications?

Yes
No

If so, what are you taking?*

What services are you interested in?*

MENTAL WELLNESS CLINIC OF COEUR D' ALENE