Edify Therapy Client and Provider Contact Form

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Please pick the option that applies to you the most:* This field is required.To continue, please indicate your role from the options provided:
I am a guardian / parent
I am from a providers office
I am a returning client
I am a new client
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Guardian / Parent Information* This field is required.Please provide the required information for identification:
Firstname
Last Name
Email Address
Phone number
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Choices for Provider Collaboration* This field is required.Select your desired interaction for effective collaboration.
I want to send records / confirm fax
I want to request records or consult over a mutual client
Inquiring about availibility
Other
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Record Request or Mutual Client Consultation - Requester Details* This field is required.Please provide your details for seamless processing of record requests or consultations involving mutual clients.
Name of the practice
Your name
Job title
Please enter your email
Office or provider phone number
Practice Address (Street, City, State, Zip)
Reason for request
Preferred PHI Delivery method (Fax nr / File link / etc.)
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Records Request / Consult Mutual Client - Client Information* This field is required.Please provide the requisite client information for efficient handling of record requests or mutual client consultations.
Client Name
Client date of birth (dd/mm/yyyy)
Client Address (Street, city, state, zip)
Client email address
Client Phone number
Please Select
Please Select
Desiree Dalkiran
Sarah Catherine Golden
Sierra Voigt
Molly Richards
Katrina Jones
Rebecca Plant
Who is treating client?
Client Insurer
Client Member ID
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Fax Number Confirmation or PHI Upload Portal* This field is required.Select Your Preferred Method: Confirm Your Fax Number or Upload Protected Health Information (PHI)
Confirm Fax Number
HIPAA Compliant Direct Upload
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Our HIPAA Compliant Fax Number is (541) 600-2324Edify Therapy hereby certifies that, as of the timestamp indicated below, the fax number displayed above is accurate and up-to-date.
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HIPAA-Compliant Document Upload Portal* This field is required.Please proceed to attach your relevant files in the designated upload area below.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Do you have any other questions?* This field is required.
YESNO
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What can we help you with?* This field is required.
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Ok
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Who was your previous therapist?* This field is required.
Desiree Dalkiran
Sarah Catherine Golden
Molly Richards
Katrina Jones
Sir Aaron Mason
Rebecca Plant
Quentin Rauschenbusch-Rowan
Arianna Kosel
Beth Halverson
Nichelle Taylor
Rose Carwile
Andy Duffield
Scott Broussard
Emily Unruh
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We have limited availability for both in-person and online therapy sessions. Please choose the "In-person or Telehealth" option to be directed to the option with the most openings at this moment. Would you like to continue?* This field is required.
YESNO
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What type of therapy are you interested in?* This field is required.Choose the type of therapy you are interested in from the options below:
Individual Therapy
Couples Therapy
Adolescent Therapy
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Which method of payment will you be using for your healthcare services?* This field is required.
Pacific Source Community Health Plans
Trillium Community Health Plans
OHP Open Card
Pacific Source Commercial
Private Pay
Other Insurance Providers
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Insurance information* This field is required.Please provide the necessary details to complete your insurance identification process
Enter your member-id
Primary insured name
Primary insured date of birth
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Client Contact Information* This field is required.Please provide the necessary details to complete your identification process
Firstname
Last Name
Email Address
Referring provider name
Reffering provider email
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Client Date of Birth* This field is required.
Date
Month
Day
Year
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Client Phone Number* This field is required.
Please enter a valid phone number.
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Client Address* This field is required.If you are using insurance, please make sure to provide the same address information as listed in your insurance records.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Client ID Card* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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Client Insurance Card* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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How are you feeling right now?* This field is required.
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Your preferred session type* This field is required.Our therapists offer the flexibility of online counseling or in-person sessions, accommodating individual preferences for each session
Telehealth
In-person & Telehealth
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Select Your Preferred In-Person and Telehealth Therapist* This field is required.Kindly choose from our therapists available for in-person sessions.
First Available Therapist
Molly Richards
Katrina Jones
Sir Aaron Mason
Desiree Dalkiran
Rebecca Plant
Quentin Rauschenbusch-Rowan
Arianna Kosel
Beth Halverson
Nichelle Taylor
Andy Duffield
Scott Broussard
Emily Unruh
Rose Carwile
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Select Your Preferred Telehealth Therapist* This field is required.Kindly choose from our therapists available for in-person sessions
First Available Therapist
Desiree Dalkiran
Sarah Catherine Golden
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Briefly Describe the Nature of Your Inquiry* This field is required.Please briefly describe the purpose or issue for which you are seeking therapy. It would be helpful to describe a good callback times for you.
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Ok
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Evaluate the User-Friendliness of this FormDid we make it easy for you? Our form collects only the essential information to ensure a smooth experience. Rest assured, this portal is HIPAA compliant, keeping your data secure.
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