Request a Consultation

McKenzie currently has limited availability and is not accepting new patients until January 2026. If you would like to be added to the waitlist, please complete the form below. Thank you!


This form aims to streamline and simplify the acceptance process into our practice. However, it's crucial to note that providing this information does not establish a doctor/therapist-patient/client relationship, and there is no guarantee of acceptance into the practice.


If you are currently experiencing a medical or psychiatric emergency, such as suicidal or homicidal thoughts, medication side effects, or any other urgent matter, please refrain from using this service. Instead, dial 911 or proceed to your nearest emergency room.


Mckenzie Smith, PMHNP, BC

Evolved Mental Health

www.evolvedmentalhealth.com

Would you like to be put on a waitlist?  *
Email *
Patient Full Name *
Name of Primary Contact (if different from patient) *
Phone number *
Preferred Contact Method
 *
Required
If your covered by insurance please list your carrier below. If you are electing to private pay please indicate below.  *
Do you have Medicare or Medicaid? Including secondary plans. *
Required
Insurance ID Number(s):
 *
Are you a resident of the State of Oregon?
 *
Zip code
 *
Date of Birth*
 *
MM
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DD
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YYYY
How did you hear about us?
 *
If you were referred by someone, please note who referred you.  If not, please note any details about how you heard about us.
Services interested in (Select all that apply)
 *
Required
What is the reason you are seeking treatment and/or current symptoms?
 *
What are your current medications? If none, please skip
Have you ever been admitted to a psychiatric hospital?
 *
Do you have a history of drug or alcohol abuse? If yes, please explain?
 *
If you have children, is DHS involved?
 *
Please list your top three (3) Mental Health goals:
 *
Why do you think Evolved Mental Health would be a good fit? 
Check out our website for more information about our practice style and vision.
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