New Client Request Form

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If you are looking for services with a specific provider, Please be sure to call or email us for availability status before completing the form below.

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Please NotE

 At Hollywood Mental Health, we use an in-house coordinated care model. We may only offer psychiatric appointments for clients that are in ongoing therapy at our clinic or are willing to engage in several sessions of therapy with one of our therapists.  

Please be aware that our clinic is not participating with Medicare, Medicaid or The Oregon Health Plan. Not all therapists are in network with the same insurance companies. See our Insurance page for information about the specific providers.

Many clinicians are in the office part time. Clients who require emergency services would be better served by another clinic where these services are available. 

Once your information from the form below is received, it will be reviewed and we will do our best to respond as soon as we are able. You can expect to hear back from us within 5-10 business days. 

For psychiatry, initial evaluations for adults are scheduled for one 90 minute appointment. Initial evaluations for children and adolescents are split into two separate 60 minute appointments: parents and caregivers are seen alone for the first appointment. This is followed by the second appointment in which parents/caregivers and child/adolescent are seen together. At the end of the evaluation diagnosis and a treatment plan will be discussed. 

Please complete the form below. The information will allow us learn about you and your mental health need. You will be contacted and an appointment may be scheduled. 


Please do not complete this form unless you have emailed or called us for the availability status of the type of service you are looking for. Thank you!

Name of Client *
Name of Client
Client Date of Birth *
Client Date of Birth
(If different)
Phone *
Phone
How did you hear about us?
Please specify if you have insurance coverage that is not an option listed above or if you plan to decline using insurance benefits to cover the cost of services.
CURRENT CONCERNS AND TREATMENT
PLEASE PROVIDE INFORMATION REGARDING THE CLIENT.
If not, please still indicate this below.
If none, please still indicate this below.
PREVIOUS MENTAL HEALTH TREATMENT
If not, please still indicate this below.
If not, please still indicate this below.

We will contact after we have had a chance to review the information submitted here. Thank you!