New Client Form
Please answer the questions below so we can find a good therapist fit.  Your answers are completely confidential.  *Please note that Outpatient mental health is not sufficient for clients who are currently in crisis.  If you are in crisis please go to your nearest emergency room or call The White Bird Clinic for immediate assistance at 541-687-4000.
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Email *
Phone number *
Legal name (first and last name) *
Preferred name (if different from legal name)
Date of birth *
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Gender pronouns *
Today's date *
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What is your preferred method of contact (i.e. phone call, email or text)? 

If we can't reach you with your preferred contact method, are you okay with us calling your phone number and leaving a voicemail?
 *
Are you located in Oregon? *
Insurance (choose one) *
If you selected "other" for insurance type, please tell us what insurance plan you have
Insurance member ID number *
Do you have another insurance plan besides the one listed above?  

If yes, please provide us with the name of your insurance plan and your member ID number.  

If no, please respond "N/A."
 *
If you have commercial insurance (any insurance other than Oregon Health Plans/Medicaid), do you also have OHP as a second insurance plan?  

If yes, please provide us with the name of the Oregon Health Plan and your OHP member ID number.

If no, please respond "N/A."
 *
Preferred therapist
Do you prefer to work with a therapist with a specific identity?  If yes, please describe. *
Do you know what type of therapy you are seeking? 
How soon are you hoping to start?
Preference for appointment type *
Do you need access to any accessibility support, such as an interpreter or any other accommodation?
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Are you seeking therapy for yourself as an individual? If no, please specify (couple, family, children, other) *
Please list the days and times you are available for appointments. *
Give us a brief description why you're seeking therapy. *
What is something you're hoping to gain? *
When thinking about your goals for coming to therapy, what is something at would be disappointing for you if it did not happen? *
Do you have any safety concerns for yourself or others? If yes, can you tell us a little bit about that? *
What is your relationship with substances? (i.e. alcohol, weed, cigarettes, prescription medicine and/or anything else) *
Is this current or past use? *
Have you sought mental health services before? If yes, what kind of services and when?  *
Do you currently take any medications for your mental health? If yes, please list your medications and who prescribes them for you. *
Are you currently experiencing suicidal thoughts?  *Please note that Outpatient mental health is not sufficient for clients who are currently in crisis.  If you are in crisis please go to your nearest emergency room or call The White Bird Clinic for immediate assistance at 541-687-4000. *
If you answered yes to the question above, can you tell us a little bit more about that? What has that been like for you and how often are you experiencing those thoughts? *
Is there any history of suicidal thoughts, suicide attempts, self-harm, or harm to others? Please answer yes or no, and if yes please tell us a little bit more about that. *
Have you ever been hospitalized for mental health concerns?  Please answer yes or no, and if yes please describe and let us know when your last hospitalization was. *
Finally, how did you hear about us?
Thank you for your time! Please leave us any other questions you might have here. Our office will be in contact with you! 
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