New Patient Inquiry Form

New Patient Inquiry Form

(You will receive a response within 1-2 Business Days)
Legal First name*
Legal Last name*
Preferred name
Date of Birth*

MonthDayYear
Date
My age is between 18 and 64 years old.

YesNo
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email*
example@example.com
Home Address (Please note: I am only licensed to see patients that live in Oregon or Washington)*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about us?*

My Therapist gave me your informationI found you myself through an online directory, such as Psychology Today, Portland Therapy Center, Therapy Den, etc.Website (drdiannaharris.com)Insurance Provider ListWord of MouthMy Doctor's Office gave me your nameOther
Prescribing Practices
I do not prescribe any controlled substances, which include...

Benzodiazepines (xanax, klonopin, lorazepam, etc.)

Hypnotics (Ambien, Belsomra, Lunesta, Sonata, etc.).

Psychostimulants (Adderall, Ritalin, Vyvanse, etc.)
I acknowledge that Dianna Harris, PsyD, PMHNP, does not prescribe controlled substances.
Insurance Information
Insurance Company*
(Please note: I am In-Network with Aetna, First Choice, Moda, BCBS - Regence, Premera, Anthem, Pacific Source, Providence. All other plans, including Cigna, Medicare, OHP (Oregon Health Plan), OHP Pacific Source, Health Share of Oregon, OHSU Health, UHC and Molina in Washington, I am out of network. We do bill UHC Out-of-Netowrk.)
If you are over 65, your commercial insurance plan (for example, Regence, Providence, etc.) is a Medicare plan. We don't bill Medicare. Please select yes or no whether you are over 65 years old.

YesNo
Member ID Number (NOT Group Number)
Font of Insurance Card

Browse Files
(Used for prescription benefits) Cancelof
Back of Insurance Card

Browse Files
(Used for prescription benefits) Cancelof
Preferred Pharmacy
Pharmacy Name
(We recommend using the following pharmacies to avoid potential delays and insurance issues: Rite Aid, Fred Meyer, Safeway, and Albertsons)
Pharmacy Address
(Street Address & City)
Clinical Information
What are the main issues you want to address and your goals for treatment?
Current Psychiatric Medications (name & dosage or N/A)
Past Psychiatric Medications (name & dosage or N/A)
Services Available

Medication Management

If you would like an assessment to determine if medication is recommended for your particular circumstance, this option is a good fit for you. I can complete an assessment and I can tell you if your problem area is best treated with medication, psychotherapy (talk therapy), or both in combination. If I recommend medication, I will manage those medication changes with you. If I recommend therapy, you will need to find a therapist (PsyD/PhD/LCSW/LPC, etc.) on your own. I do not provide therapy services.

If you are currently taking psychiatric medication and want to re-assess if medication changes may need to be made, this service is also a good fit.

Lastly, if you are taking psychiatric medication and are stable on your current medications and need refills of your existing medication, this service is also a good fit, as long as you are not taking controlled substances. I do not prescribe controlled substances. Controlled substances include all psychostimulants for ADHD (Adderall, Ritalin, Vyvanse, etc.), all benzodiazepines (Zanax, Klonopin, lorazepam, etc.), some sleep aids (Ambien, Sonata, etc.), and Gabapentin.

Services NOT available…

Weekly or biweekly 45-60 minute Psychotherapy appointments - Although I can provide brief and supportive therapy as part of your treatment with medication, these services are time-limited and not offered at the typical therapy time frames (such as 45 to 60 minute appointments, occurring, weekly or biweekly), found with therapists that provide ongoing talk therapy.

ADHD Treatment - I don't diagnose or treat ADHD.

Please check the box below to indicate you understand the difference between the two services and want to proceed with medication management services.
I am seeking Medication Management Services
This service is provided as a way to make the process of getting accepted into a particular provider's practice more simple and efficient, but it can only be used if you agree that providing this information does not mean any doctor/therapist-patient/client relationship is being formed, and that no guarantee is provided that you will indeed be accepted into the practice. If you do not hear back or the provider informs you that he/she is notthe right fit for you, you are welcome to submit requests to other providers. If you are or believe you are experiencing a medical or psychiatric emergency. including suicidal or homicidal thinking. side effects to medication. or any other urgent or time-sensitive matter. do not use this service. Instead call 911 or go to your closest emergency room. If I do not agree. I will not submit this form.
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New Patient Inquiry Form

Prescribing Practices

Insurance Information

Preferred Pharmacy

Clinical Information