Therapy interest form
This interest form will help us to find out if we will be able to offer you services. Our Front Desk will give you a call as soon as we could to inform you of the status of your interest form and options. Please note that we may or may not have an opening at the present time.

Please write N/A if the question/s does not apply to you.

If you are having difficulties with this form, please call 360-799-5782 or 360-799-4556

Please download OhMD app so that we could text you or you could text us for an update on the status of this interest form - https://www.ohmd.com/download/

Thank you - Pathways MHS
Email *
ALL OF OUR APPOINTMENTS ARE CONDUCTED VIA TELEHEALTH (AUDIO/VIDEO) and/or Phone SESSION DUE TO COVID-19. You need to be a resident of WASHINGTON STATE for us to provide Telehealth services to you.
Full Name (The person who will be receiving services) *
Street Address (The person who will be receiving services) *
City, State, Zip (The person who will be receiving services) *
This appointment is for? (yourself, child, spouse or significant other) If not for you, pls. enter the name of the person who will be receiving counseling services. *
I/We need a provider that speaks *
Preferred Name *
Gender Identity *
Date of Birth *
MM
/
DD
/
YYYY
Age? *
Cell Phone *
You were referred to us by whom *
Have you been in counseling/therapy before? *
Do you prefer a male or female provider? *
Which location would like to seek counseling *
I am looking for *
Have you been diagnosed with any of the following condition/s? *
Required
Please list current medications (prescribed and over-the-counter): *
Alcohol & Drug or Gambling History: *
Any pending legal case? *
Pls. describe your pending legal case below. *
Have you been hospitalized for mental health conditions? *
What is the reason for seeking counseling or therapy? *
Next
Never submit passwords through Google Forms.
This form was created inside of Pathways Mental Health Services. Report Abuse