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 206-203-2166 instead. 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, someone will attempt to contact you within 7 business days.

First and Last Name, Preferred Name if Different *

Pronouns

Phone Number *

Email Address *

Date of Birth *

YYYY

In accessing care, I hope to: *

Use my Premera Insurance (in-network)

Use my Regence Insurance (in-network)

Use my First Choice Insurance (in-network)

Use my Aetna Insurance (in-network)

I understand Reproductive Resilience 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.

Other:

Please tell us which is closest to your current experience... *

Trying to Conceive/Preconception

Infertility/Fertility Treatments

Pregnant/Gestational Parent and/or Lactation and Medication

Non-Gestational Parent/Partner, expecting a child or postpartum

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

Postpartum/Birth Trauma (within 6-12 months of delivery/welcoming a child)

Postpartum/Transition to Parenthood (6-12 months postpartum)

Peri-menopause/Menopause

Menstrual related mood difficulties

Other:

Required

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

I understand and agree.

We do our best to match new clients with clinicians, based on clinician area of expertise, insurance, and availability. However, if you are looking to connect with a specific clinician, please let us know who that is:

Melissa Rubin, PMHNP-BC, ARNP, CNM, PMH-C

Candace Mabbitt, PMHNP, CNM, WHNP-BC, ARNP

Ariel Brantley-Dalglish, PMHNP-BC, CNM, ARNP

Clear selection

How did you find out about Reproductive Resilience? 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

Saw the sign in West Seattle

Other:

Required

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