New Client Initial Screening
After completing this form, our admin team will get right back you to discuss options for therapy. Completion of this form helps us to better match you to the therapist who best fits your needs. We appreciate your interest and patience.
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Email *
May we contact you via your email? *
Today's Date *
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Your Full Legal Name (needed for billing and insurance verification) *
Name you wish us to use *
If you are filling this form out for someone else please indicate who and what their relationship is to you *
Your Phone Number *
May we contact you on this phone number? *
Your Birth Date  *If you are under 14, unfortunately, we are not able to work with you at this time *
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How did you hear about us? Who Referred You? *
Required
How will you be paying for your services? * Please note our therapists do not all carry the same insurance panels and there may be a wait time for services for clients needing to use certain insurance depending on availability. *
IMPORTANT: If one of your insurance panels is Oregon or Washington Medicare, or Washington Medicaid, we are not able to take those insurance companies at this time.

*What insurance company do you currently have? If you carry two or more insurance companies, please select both options.  If you do not see your insurance listed here we do not take it at this time.
 *
Required
Is your primary residence in Oregon or Washington? *
What are your top 3 mental health concerns right now?   *
Have you ever been given a mental health diagnosis before? If so, what was the diagnosis/es? *
Have you been hospitalized for mental health issues in the last 5 years? *
Required
All of our therapists are online only providing HIPAA compliant telehealth sessions.  This will require that you have a stable internet connection and a laptop/desktop computer for sessions and completion of online intake paperwork.  Do you have access to internet and a computer? *
Required
Would you like to keep up to date with the clinic changes via email?  If you check yes, we will use the email supplied on this form to send you updates. *
Required
We cannot guarantee that any particular therapist will have openings at the time of interest, however is there a specific therapist that you are interested in working with from our team?  *
Thank you for completing our new client form.  Your answers help us to fit you to the best possible therapist on our team to meet your clinical needs.  An intake coordinator will contact you within 24-48 hours to begin next steps. 
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Arin Wallington.