The Lotus Center for Neurodiversity Waitlist Form
Join our waitlist today!

*Please be aware that filling out this form does not serve as a guarantee to receiving our services. In addition, there is no way to provide an approximate wait time, as moving from the waitlist to becoming a client is based not only on length of time on the list but also based on level of need (with higher need clients being placed at higher priority).
Sign in to Google to save your progress. Learn more
Your Full Name *
Your Email Address *
Your Phone Number *
Your Medical Insurance Carrier
IMPORTANT NOTE FOR OHP MEMBERS:
Our clinician is currently a registered associate, and due to Care Oregon’s decision to reinstate reimbursement policies for associates—effective July 31, 2025—she is no longer able to accept new clients covered by the Oregon Health Plan (OHP) at this time. Please reach out to us if you have any questions.
 *
Who are you seeking services for?
Please state "myself" or the full legal name AND preferred name of the individual needing services.
 *
Is immediate support needed?
If yes, we will reach out to you via email with resources and potential provider referrals. 
 *
What services are you interested in?
Choose all that apply
 *
Required
Which would you prefer?  *
Additional Information
Tell us more about who the services are for and your reason for reaching out. Please include;

Age (please include the date of birth- dd/mm/yyyy)

Symptoms (please ensure to mention if there is current suicidal ideation, past or recent suicide attempts, risk of incarceration, etc.)

Existing Diagnoses (Suspected and/or official.)

If person seeking services attends school;
School of Attendance (please note any other system involvement including DHS, justice systems, etc.)

Special Education Services (Do you/your child have an expired or active IEP or 504 plan?)

 *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms