You have accessed this page in error - please DO NOT continue as any data submitted will be automatically discarded. If you arrived here using a link from a source other than the provider's profile page on our website then note that, due to recent changes in our intake process, previous links to this form are now no longer valid. Please return to the profile page of the provider you intended to submit for and start again.
Click here to go to the provider listing page.
If you continue to see this error message, and you are certain the provider you are applying with has current openings, then please contact our offices at (360) 329-2055 for more assistance.
Congratulations on taking steps toward 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, the better we can help you.
Filling out this form is not a guarantee of an appointment with any, or a specific provider, nor of a time frame in which an appointment may occur. Not all providers are accepting new clients, have waitlists, or are a suitable fit for every client. You can view our providers and their new client availability by clicking here.
The 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. The information you give here may be reviewed with you by your provider during your first session in order for them to gather more details or obtain up-to-date information. 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 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.
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 benefits 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. We do not accept any EAP programs, CHPW, or Medicare.
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 third-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 your multiple intake submissions will ALL be put on-hold until admin staff has time to manually determine which of your submissions 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.
King Health does not have on-call providers and does not provide the wrap-around or intensive outpatient services usually required by clients who are in crisis. If you are in a mental health crisis, you will need to contact either emergency services (911), or a community mental health center such as SeaMar, UnityCare or Sunrise Services to support you in a timely manner.
Please note our submission response time at the top of this form, which gives the average time for your form submission to be reviewed.
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 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.
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).
IMPORTANT : You've selected Psychiatric services - if you intend to use MOLINA APPLE 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.
NOTICE : We do not accept Employer Assisted Programs (EAP). You may continue, but please be aware that you will need to use your regular health insurance or pay cash for your appointments.
NOTICE : We are sorry, but we can only accept Molina Medicaid insurance. Please return and resubmit your intake if your insurance changes to Molina Apple or to a non-state funded insurance in future. Do NOT continue to submit this form as your intake will be rejected due to this insurance conflict.
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.
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 SUBMIT button below to proceed.
The form may take up to 60 seconds to process - please be patient and do not click the SUBMIT button multiple times.
You will see an acknowledgement page once the form has been processed fully.
King Health is now Emerge Clinic
Tel: (360) 329-2055
Fax: (866) 728-2859
315 Lakeway Drive
Bellingham, WA 98226
Billing Inquires Only
Tel: (360) 329-2055 x802
National Suicide Lifeline
Rape, Abuse, Incest (RAINN)
National DV Hotline
National Child Abuse Hotline
National Suicide Chatline
VOA Crisis Chatline
Rape, Abuse, Incest (RAINN)
National DV Chatline
24/7 Teen Crisis
24/7 Crisis Textline