• New Client Referral Page

    Us this form to refer a new client to us.

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    This form is confidential and secure.  All information is stored and transmitted with HIPAA-level security and Encryption.

     

    NOTES:

    • If you are looking to refer someone for psychological testing and/or an Autism evaluation:  Ann Uherek, PsyD is our psychologist who provides these assessments.  Dr. Uherek does not accept insurance.  To refer to Dr. Uherek, contact her directly at 206-729-2101.
    • All of our providers offer telehealth options, and some offer in-person sessions.
    • Pay special attention to office locations.  Client's location dictates which office would be appropriate.
    • If the referral is appropriate, we will let you know, and ask the client to complete an online request.
    • Clients may self-refer at any time at our New Client Portal.
    • Once the requests for new appointments is accepted, the client is automatically placed on a waitlist for services.
    • The wait time can be 1-16 weeks, depending on:
      • Office location
      • Specific needs of the case
      • Degree of flexibility of schedule, location, and provider.
      • Staff availability.

     

  • After we receive your request:

    We will review the request, and respond as soon as possible.

  • CONTACT INFO:

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • WHO ARE YOU CONTACTING US ABOUT?

  • SERVICES:

    *NOTE. We might be able to help with treatment that is court-ordered, but we do not provide court-related evaluations/reports of any kind (except to confirm attendance in treatment), chemical dependency evaluations or treatment, or formal anger management programs. In the case of parenting plan/custody disputes: We have very limited ability to provided counseling services for children in these situations. We are unable to provide any kind of evaluations, treatment reports, or recommendations for custody/parenting plan disputes.
  • Desired services (check all that apply):

  • NOTE ABOUT PSYCHOLOGICAL AND AUTISM SPECTRUM EVALUATIONS:  We have one provider who can provide these services:  Ann Uherek, PsyD. 

    Do not use this form for psychological evaluations.  Instead, contact her directly for more information.    206-729-2101

  • LOCATIONS:

  • Office location preference: To get the best chance of an appointment that will work for you, choose as many locations as possible that will work for your client/patient.. We presume that they are willing to consider telehealth unless you NO TELEHEALTH below.
  • Which Insurance plan(s):

  • NOTES ABOUT INSURANCE:

    Acceptance of specific insurance plans varies by provider.

    *TRICARE MEMBERS: We do NOT have any providers who currently are contracted with TRICARE plans. However, we may have limited ability to accept TRICARE on an 'out-of-network' basis. Currently, we do not have any providers who work with Military One Source.

    ** MEDICAID:  We are unable to accept any plans.

    *** MEDICARE and MEDICARE ADVANTAGE plans: We have a very limited ability to accept Medicare plans.  We do not accept all Medicare Advantage plans.

    Employee Assistance Plans (EAP):  The acceptance of EAP plans varies by clinician.

    MEDICAID AND MEDICARE? Unfortunately, because of the laws regarding these plans, we are, generally, unable to work with people who have BOTH plans under the QMB program.

    PLANS WE DO NOT ACCEPT:

    • Veterans Administration plans, CHAMPVA, or VA Community Care plans.
    • All 'Provider One" Plans:
      • Labor and Industries (L&I)
      • Crime Victims Compensation (CVC),
      • Adoption Support, 
      • **Medicaid/Apple Health
      • Developmental Disabilties Administration (DDA)
    • Auto insurance or other non-health insurance plans*****

    *****Auto Insurance or other insurance plans: We generally do not accept these plans.

    FINANCIAL ASSISTANCE: We have a very limited capacity to provide financial assistance with the cost of care. Each clinician manages their own uncompensated care case load.

  • PLEASE NOTE: As the pandemic has drawn on, increasing numbers of people are contacting us in need of help. We have been overwhelmed with the number of phone calls and emails requesting new appointments. We will do our best to respond as soon as possible.

  • Should be Empty: