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Please submit this form to learn about therapy, acupuncture, or medication management. We’ll get back to you within one business day. Depending on the provider you'd like to work with, our waitlist is approximately two weeks to six months.

Please note: We are not providing ADHD assessment or ADHD medication management at this time.

Email *

First & Last Name (Legal Name) *

Preferred Name

Pronouns

Phone Number *

May we leave a voicemail at this number? *

Yes

Date of Birth *

YYYY

Do you live in Oregon? If not, can you attend therapy sessions at our Pearl or NE location? *

Yes

Insurance *

Blue Cross Blue Shield/Regence

Aetna

PacificSource

Moda

Cigna

Providence

Kaiser - if your request is for medication, you need to do two trials with your Kaiser PCP before our PMHNPs can work with you.

OHP

Out of Pocket

Other:

Member ID *

If you'd like us to check your insurance benefits, please provide your legal gender.

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