New Client Inquiry


Estimated time to complete : 5-10 minutes

Congratulations in taking steps towards a healthier existence, and towards getting the support you need. Moving towards improvement begins with us getting to know your needs and your wants. The better we understand you, the better we can help you.

What to expect

First step is to complete this form, which gives us some idea of who you are and what your needs are. We need this information to determine if, and how, we can best help you. Once you have completed this form and our office staff and providers have reviewed it, we will contact you to do an intake when an opening with an appropriate provider is available. Note that we cannot guarantee that a suitable provider will be available, or the length of time before an opening will be occur. Once you have been selected for intake, this initial intake evaluation session* (generally 45 minutes) will be conducted by a staff psychiatric provider who is qualified to diagnose mental health as well as medical issues that may be creating or affecting any of your presenting issues (unfortunately licensed counselors are not qualified to identify medical issues and there are many behavioral health issues that are actually caused or exacerbated by underlying medical issues). The intake session is not intended to explore relational or emotional issues, but is an evaluation and therefore rather more fact-finding in nature. Once your intake has been completed you will be able to set up your regular appointments with your chosen provider.

NOTE: Filling out this form is not a guarantee of an appointment with any provider, or a time-frame in which an appointment may occur. Not all providers are suitable fit for every client, and while some providers may have current openings, others may not. Rest assured that we will contact you as soon as a suitable opening occurs, but we understand that you are under no obligation to wait.

Same Day Appointments For New Clients

WE ARE SORRY BUT WE CANNOT ACCEPT SAME DAY NEW APPOINTMENTS. This is because we have paperwork you must fill out prior to your first session. You also will need enough time to call your Insurance company and obtain your insurance benefits prior to your first appointment. You must receive a confirmation for your requested appointment time. Please do NOT show at our offices without receiving this confirmation from us via email.

Insurance Benefits Information

Please note that if you plan to use health insurance you should come to your first visit with your current insurance benefit information checked and confirmed as you may have a deductible to meet before treatment is covered by your plan. Some services we provide may not be covered by insurance - please check with us if you are not sure.

Confidentiality Of Submitted Form Information

Any information submitted using the form below will be encrypted before it is transmitted to our offices, where it is securely stored according to HIPAA regulations. Your confidential information is sent to us directly and is not stored unencrypted at any point in any thrid-party services or hosts.

Do not resubmit this form

Do not submit multiple versions of this form for the same client. We have only one profile per client and multiple intake submissions will all be put on-hold until admin staff have time to manually determine which version is the most accurate and therefore WILL significantly hold up your intake process. If you have previously submitted incorrect information please call or email to update, giving your name and date and time of your submission.

* You may decline the psychiatric evaluation portion of the intake if you have had a psych eval conducted by a qualified psychiatric provider elsewhere in the last 12 months and can provide a copy of the evaluation, or if you have any objection to receiving an evaluation. Please ask us for a declination waiver form.


 

For Yourself Or Another Person?


Note: In Washington state, children over the age of 13 are legally allowed to engage in their own self-directed mental health treatment without parental consent. (See Chapter 71.34 RCW) However, we fully encourage the participation of parents in their child's care.

Okay, great, you are filling out this form for someone else. Please now answer the rest of the form as the client (their birthdate, insurance, etc).


 

What Services Are You Most Interested In?


 

You may select more than one service.

 

 


IMPORTANT : You've selected Psychiatric services - if you intend to use MOLINA insurance please click here. If you are using other insurance then please continue to complete the form.


 

 

Clinic Location


Please indicate which location is the most convenient for you to see your provider. Note that not all providers may be available at all locations. Not all providers offer mobile or telemedicine (online sessions). Insurance may not cover online sessions. Additional fees may apply for mobile sessions.

 

We Need To Know Some Details About You To Set Up Your Chart


 

Enter only your legal first name. No middle names, nicknames, names of partners, etc. If you go by a different name (such as a nickname) from your legal name, please say so in the notes section at the bottom of this form.
Enter only your legal last name. No middle names, nicknames, names of partners, etc.
Note: An email address is required. The nature of email communication means confidentiality can not be guaranteed.

 

Enter the sex listed on your birth certificate. If this does not match your birth certificate then your insurance claims will be denied and you will be responsible for the full amount due.
If you have specific pronouns you wish to have known, you should select 'other' and include your preferred pronoun after your preferred gender identity. If you wish, you may also include pronouns in more detail in the 'In Your Own Words' section at the end of this form.

 

NOTE: If you are under 18 at time of initial appointment we will require a Financial Guarantor Form signed by an adult who will assume full financial responsibility for any unpaid bills. This form can be found in your portal documents - please download and print. The guarantor will need to leave their credit card details on file and will be automatically billed any amounts not paid at time of service. You will not be able to see any provider without this signed form, so please make sure that it is complete and presented to reception prior to the first appointment.


 


 

 

Will You Be Paying With Insurance?


 


NOTICE : We do not accept Medicare insurance. Even if you also have a commercial insurance as secondary, we cannot accept your insurance (primary insurance must be billed). You may continue but please be aware that you will need to pay cash for your appointments.


 

EAP (Employee Assistance Program) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.
If you are using a smart phone you can take a photo and upload here. Alternatively, if you have access to a scanner you can scan and upload.
Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png bmp tif psd pdf.
If you are using a smart phone you can take a photo and upload here. Alternatively, if you have access to a scanner you can scan and upload.
Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png bmp tif psd pdf.
Enter the person's gender. If this is incorrect then your insurance claims will be denied and you will be responsible for the full amount due.
Please put the address on a SINGLE line eg. '123 Some St, Cityscape, WA'
You will find this on your insurance card
Enter the person's gender. If this is incorrect then your insurance claims will be denied and you will be responsible for the full amount due.
Please put the address on a SINGLE line eg. '123 Some St, Cityscape, WA'

 

A Little About You


 

Please be detailed with medication, dates of use, and dosage. Indicate if you are currently using the medication.
Please select more than one by holding CTRL key while selecting. If your diagnosis is not on this list, please select 'other'.

If you are feeling suicidal right now, have a plan or intent, please call

911

or go to your

nearest hospital


If you have been feeling generally suicidal, but have no specific plan, please call the national crisis suicide helpline

1-800-273-8255

or you can also chat online

Suicide Chatline


Suicidal feelings are not uncommon and can be difficult to handle in the moment, but as bad as you might feel, it is important to remember that like any feelings, those moments will pass and feelings will go. Suicidal feelings are temporary ways that your mind lets you know you need help. We will help you towards understanding these feelings, reducing the intensity, and working towards healing growth. Making an appointment with us is a great first step in dealing with these feelings, but remember that we can only meet with you at your scheduled appointments and we are not your first port of call when these feelings become too much for you. It is essential that you call 911 or the crisis line as appropriate when you start to feel suicidal, and important that you keep your scheduled appointments with us and tell us about your feelings during your session.


 

 

Areas I Might Like To Work On


Note: Not all providers offer these options. Please refer to the provider's profile page for the options they offer. You may select one or more option

 

What Qualities Do You Prefer In Your Provider?


 

Note: You may select one or more option

 

In Your Words


This is your care, your time, and we want to hear your needs and a little of your story. Give us a brief introduction to the issues at hand. And if you'd prefer to wait to tell it to your provider then that is okay too.

Please limit your writing to 250 words or less.

 

 

How did you hear about our services?


Help us discover the most effective ways to reach you. With your help, the funds we would have spent on ineffective marketing can instead be spent on improving services.

 


You MUST click the continue button below to proceed. The form may take a few seconds to process - please do not click multiple times.