New Client Request Form

Please NotE

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.

While we do bill to insurance companies a provider is in network with, we currently do not bill out of network insurance companies but are happy to provide you a bill that you can submit to your insurance company directly. We are not in network with any EAP panels.

Many clinicians are in the office part time. Clients who require emergency services may 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 3-5 business days. 

For psychiatry, initial evaluations for adults are scheduled for one 60-90 minute appointment. Initial evaluations for children and adolescents are often 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. 

Due to practitioner availability, your specific clinical needs, and a number of other factors, we are not always able to accept everyone seeking services. Please accept our apologies in advance.


Name of Client *
Name of Client
Client Date of Birth *
Client Date of Birth
(If different)
Phone *
Phone
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.
Contact and Appointment Details
Please add any further information about your previous correspondence with our providers or staff.

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