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.
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.
Most groups are paid by self-pay either because they are not covered by insurance or the provider running the group may not accept your specific insurance. Please complete the insurance sections of this form so that our staff have your information on hand if there is a possibility that you are able to make use of your insurance.
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. 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.
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).
We cannot guarantee that any group or workshop will be covered by insurance. If insurance coverage is not available then you will be required to pay the cost of the groups or workshops.
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.
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;
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.
Groups and workshops are activities that result in changes such as growth, insight and healing, as well as being fun and shared events. Although the group or workshop already has an established goal, setting a personal intention to achieve something specific helps in making that a reality and can improve your chances of getting what you want from your investment in yourself. It may be as specific as "I want to learn skills that will help me remain calm in times of workplace stress" or as vague as "I want to learn whatever comes to me during the process".
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