New Client Interest Request

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Please complete the following brief questionnaire so we can help you find an appointment with the provider who can best fit your needs and availability. If you prefer, you can call 206-486-6167 instead, however we are generally slower to respond to voicemails.

PLEASE do not include confidential health or other personal information in this form, as it is not secure and encrypted.

Once you complete this form, our practice manager, Tori, will reach out to assist you further!

First and Last Name, Preferred Name if Different *

Pronouns

Phone Number *

Email Address *

Date of Birth *

YYYY

I am interested in: *

Individual Psychotherapy

Couples/Family Therapy

Birth Plan or Postpartum Planning Session (please note: this service is only available virtually)

Required

Types of service you are seeking (PLEASE NOTE: Our practice is closed on evenings and weekends and we primarily work with clients managing reproductive experiences): *

In-Person Sessions Only (West Seattle)

Virtual Sessions Only

Open to Either or Both

Please share a little more about what you're hoping to address in therapy and any scheduling needs (including preferred days or times). One or two sentences helps us match you with the best therapist for your needs! *

Preferred Clinician (if any)

Darby Frye

Emily Schneider

Lesli Desai

Megan Slade

Open to any provider

Is this your first time seeking mental health support?

Yes

Clear selection

In accessing care, I hope to: *

Use my Premera Insurance (in-network)

Use my Regence Insurance (in-network)

Use my Kaiser PPO/First Choice Insurance (in-network)

Use my Aetna Insurance (in-network)

I understand Seattle Therapy is out of network with all other insurance plans at this time. I am planning to pay out of pocket and would like to receive superbills to submit for out of network coverage.

Our providers specialize in reproductive mental health and see clients across a wide spectrum of experiences. Please check boxes for what is relevant to current experience... *

Trying to Conceive/Preconception

Infertility/Fertility Treatments

Pregnant/Gestational Parent

Non-Gestational Parent/Partner, expecting a child

Pregnancy Loss in the last 6+ months (miscarriage, stillbirth, neonatal loss, TFMR, abortion, etc)

Acute Postpartum/Birth Trauma (within 6 months of delivery/welcoming a child)

Postpartum/Transition to Parenthood (6-18 months postpartum)

Childfree-not-by-choice

Perimenopause/Menopause

General Life Transitions

Depression, Anxiety, and OCD Support

Identity and Boundaries

Other:

Required

In order to receive services from Reimagine, I understand that the client(s) must be physically located in Washington state at the time of each appointment.

I understand and agree.

How did you find out about Reimagine? If you're willing to share the name of the provider or clinic who referred you, please add it to the "Other" box *

Online Search

Referral from another provider - please list their name in the "Other" box if you feel comfortable sharing

Referral from a current/former client

Other:

Required

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