New Client Inquiry Form for Care at Restore Therapy

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Thank you so much for your interest in Restore Therapy! At this time, we are currently at capacity. After completing this form, we will save your information for our wait list and reach out once space becomes available.

Email *

Full Name of Prospective Patient *

Age *

Please list the name of the primary contact for this referral and your relationship to the client (ex. Pam Smith, Mother). If you are the client you may write "Self". *

Email *

Phone number *

OK to send SMS for intake coordination? *

Address *

Date of birth *

Gender Identity *

Race/ Ethnicity (optional)

Insurance Provider

Below are all the insurances we are in network with. If you are interested in out of pocket services, please specify below. Thank you!

Pacific Source (Therapy and Psychiatry)

CareOregon/ HealthShare OHP (Therapy only)

Kaiser (Therapy only)

Moda (Psychiatry Only)

Blue Cross (Psychiatry only)

I do not have the above insurances and can pay out of pocket

Other:

Insurance ID (required) *

What is your availability to come to appointments? *

Do you prefer coming into the office, virtual or a little of both (hybrid)? *

Office

Virtual

Hybrid (in office and virtual)

I don't have a preference

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