Clarity Health Request for Care

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Request for Care Form

Email *

A Few Details-Please Read

Thank you for your interest in our services! We have made this pre-screening form to protect your time as well as our own. It is important in the clinician-client relationship that there be a good fit and that teleh-health is appropriate for your care. Our hope is that this form will help both of us figure out if we might work well together.

Not all conditions are appropriate for tele-health or our practice, and our desire is to direct you to the best place for you. We ask that you please read through our FAQS on the website, this document, and answer a few questions before scheduling a 10-minute phone consult with us. Most of our visits are via Tele-health at this time. However, we do offer some in-person visits in Portland.

We predominantly work with people who struggle with ADHD, depression, anxiety, social anxiety, stress, relationship issues, job/school stress, life transitions, loneliness, life dissatisfaction, dissatisfaction with society, and struggles with identity in a variety of forms. We also work with thyroid and gut disorders. We work well with those who want to improve their lives, and are interested in doing things differently to make that happen.

We do not offer services for substance or alcohol use, severe and persistent mental health conditions, schizophrenia, bipolar 1, anorexia nervosa, or psychosis at this time.

While we incorporate therapy into our visits, we do not offer weekly therapy sessions. We recommend you have a separate therapist you see on a regular basis.

Our goal is not to be your provider for many years on end. Our goal is for you to gain confidence in yourself and in your own abilities to navigate through struggle and feel at peace despite what life happens to throw your way.

How did you hear about us?

Psychology Today

Google

School/University

Therapist (please let us know your therapists' name if you are comfortable)

Other:

Clear selection

Your name: *

Date of birth

Best phone number: *

State of residence (If in school, list state where you are in school): *

Our providers are currently in-network with Aetna, BCBS/Regence (one provider, OR only), Cigna, Moda, First Health, Pacific Source, Samaritan and Providence. Many of our clients are self-pay. We will always provide a superbill which you may submit to your insurance company for reimbursement. Our private pay rates are listed on my website but vary by provider. * Please contact your insurance so you understand your out-of-pocket and deductible responsibilities. *

I have Medicaid/Medicare/OHP or other government sponsored insurance

I have Blue Cross/Blue Shield, Regence, or another BCBS insurance

I have Providence Insurance

I have Aetna Insurance

I have Cigna Insurance

I have MODA Health Insurance

I have First Health

I have Pacific Source

I have United Healthcare

I have Samaritan

If OHP, please list specific company (i.e. Samaritan OHP or Pacific Source OHP)

I plan to self-pay

Other

Briefly describe what you have been experiencing that has led you to seek mental health services at this time: *

Do you have or think you may have any of the following symptoms or conditions? *

Attention Deficit Disorder

Depression

Insomnia

Anxiety or Panic Disorder

Bipolar Disorder or Mood Swings

Substance Use (Alcohol, cannabis or other substances)

Obsessive Compulsive Disorder

Eating Disorder-Anorexia Nervoxa

Eating Disorder-Bulemia or other

Personality Disorder (i.e. Borderline personality disorder)

Thyroid condition, issues with gut health. or other physical condition

Current suicidal thoughts, ideation, plan or intent

None of the Above

Other:

Required

If seeking care for ADHD:

Note for ADHD care: we require past medical records, substance use testing, a Cognifit test for some, and pull medication history from a national database for safety.

I am seeking a first diagnosis

I have previously been evaluated for ADHD

I have had neuropsychological testing done and have the report

I have been diagnosed by my primary care provider or other health care provider

My therapist thinks I have ADHD

Other:

Please list any medications you are currently taking for mental or physical health (or type N/A): *

Please list any medications you have taken in the past for mental health (or type N/A): *

Alcohol use: *

Never

Rare (a few times per year)

1-3 drinks per week

4-6 drinks per week

7+ drinks per week

Occasional binge (4-6 drinks)

Occasional binge (7+)

I think I might drink too much or others think I might drink too much

Other:

Required

Current cannabis or other recreational substance use (in the last 6 months): *

Never

Use of cannabis or other recreational substances

1-3 times per week

4-6 times per week

Daily

Several times per day

I think I might use too much or others think I might use too much

Other:

Required

Please list all current medical conditions. Type N/A if none. *

Have you ever been hospitalized (Inpatient or Intensive Outpatient) for any psychiatric reason? *

Yes

Other:

Required

If so, when?

Is there anything else about yourself you think would be helpful for me to know about you before our phone consult? It can be helpful to list any goals you have. Feel free to list any questions here as well.

We appreciate your time and thank you for filling out this form. We will reach out to let you know if we think we might be a good fit based on the information given here. Feel free to reach out as well with any additional questions.

In good health,

The Clarity Health Team

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