New Client Intake


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.

The Intake Process

Our intake is a two-part process. Once you have completed this intake form and our office staff have set up your health chart, we will contact you to set up the in-person portion of the 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 both portions of the intake have been completed you will be able to set up your regular appointments with your chosen provider.

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.

* 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.

 

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 the gender 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.

 


 


 

 

Will You Be Paying With Insurance?


 

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.
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.
You will find this on your insurance card

KAISER CORE HMO

IMPORTANT!

Kaiser Core HMO has a specific requirement that, prior to your session, you MUST call them to have your session pre-authorized or they will deny your claim and you will be responsible for the full session fee. The call should take only a few minutes to complete. The number to call is;

1 - 888 - 901 - 4636

 

 

A Little About You


 


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
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
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 as much of your needs, or your story, as you want to express. And if you'd prefer to wait to tell it to your provider then that is okay too.


 

 

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.