Let’s work together.

Interested in working together? Fill out some info and we will be in touch shortly!

Name

First Name

Last Name

Are you seeking services for yourself or someone else?

Self

Someone else

Phone

(###)

###

####

Were you referred by another provider? If so, please include the provider name and any relevant details.

Insurance Type

We are in network with Wellmark Blue Cross Blue Shield. Our clinical interns are zero cost regardless of insurance coverage.

Preferred Provider

Kristten Buttermore and Kelly Binkowski are currently full.

Alexa Bilyeu (clinical intern)

Nathan Birtell (clinical intern)

Abbie Stucker, t-LMHC

No preference

How did you hear about us?

Brief Symptom(s)/Reason for Seeking an Appointment:

Disclaimer:
This form is intended to collect requests for new services at Cultivate Wellness and Vivant. Please note that submitting this form does not establish a client-therapist relationship. By completing and submitting this form, you are voluntarily providing information. Please do not include highly sensitive or detailed personal health information (PHI). The information provided will be used only for the purpose of determining service availability and will not be disseminated.

Initial communication will occur via email. If you move forward in becoming a client, all future communication will take place through our secure client portal.

Cultivate Wellness

214 5th Street

Ames, IA 50010

Email
Phone: 515-212-7379

Fax: 515-552-1274

Contact the Suicide Prevention Hotline at 1-800-273-TALK (8255) or visit your local emergency department if you are having thoughts of self harm or suicide.

Cultivate Wellness is not a crisis service.

Made by Kristten Buttermore, LMHC with YOU in mind

© 2022 Cultivate Wellness PLLC

Cultivate Wellness does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, gender identity, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and firing of staff, selection of volunteers and vendors, and provision of services. We are committed to providing an inclusive and welcoming environment for all members of our staff, clients, volunteers, subcontractors, vendors, and clients.