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.
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.
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.
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.
Please note that, due to liability issues, we do NOT supply ESA (Emotional Support Animals) letters. This is a practice-wide policy affecting all providers and is non-negotiable.
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 submit multiple versions of this form for the same client. Our system allows for 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.
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).
NOTE: If your mental health challenges are such that you believe you may not be able to consistently attend your appointments then please be aware that we are not state or government funded and therefore do need to charge for no-shows or late-cancels, regardless of whether or not they may be due to a particular mental health issue. Community mental health centers may offer support that is able to be more flexible with regards to no-show and cancel fees. Please know that our clinics and services are set up to accommodate clients who are functionally able and stable enough to attend appointments without limitation.
Should you wish to continue, please pay close attention to our practice policies, and in particular the associated fees. We reserve the right, at any time, to refer out any client who we believe is too high acuity for our services.
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.
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.
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.
If you are feeling suicidal right now, have a plan or intent, please call
or go to your
If you have been feeling generally suicidal, but have no specific plan, please call the national crisis suicide helpline
or you can also chat online
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.
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.
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.
Bellingham ClinicTel: (360) 329-2055Fax: (360) 547-7780
21 Bellwether Way
Bellingham, WA 98225
Barkley ClinicTel: (360) 329-2055Fax: (360) 547-7780
3130 Howe Place
Bellingham, WA 98226
Billing Inquires Only
Tel: (360) 329-2055 x802Fax: (360) 547-7780
New Client Inquiry
National Suicide Lifeline1-800-273-8255
Rape, Abuse, Incest (RAINN)1-800-656-4673
National DV Hotline1-800-799-7233
National Child Abuse Hotline1-800-422-4453
National Suicide Chatline
VOA Crisis Chatline
Rape, Abuse, Incest (RAINN)
National DV Chatline
24/7 Teen Crisis
24/7 Crisis Textline