Talking Twenties New Request

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First, we'll need some information about you
Client Name
Email
Phone Number
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How may we contact you?* This field is required.
Text Message
Email
Phone Call
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What are the main reasons you are looking for help?* This field is required.
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How do you want help with those issues?* This field is required.
Prescription medication
Routine (weekly/biweekly) therapy
Brief therapy as part of medication visits
Someone to help me choose the best path!
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Do you need a provider who specializes in:
ADHD & can prescribe stimulant medication
First responders
Healthcare workers
LGBTQIA+ mental health
Pregnancy/postpartum
Other
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Is there a provider you would prefer to see?Read more about us here
Please Select
Please Select
Match me with the best fit!
Angela Lee
Anicka Meyers
Heather Webster
Marisa Bell
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Which state do you live in?* This field is required.We can only provide services to residents of Oregon or Washington.
Oregon
Washington
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Would you prefer to meet in-person at our Portland office?
YESNO
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Birth Date* This field is required.We can only provide services to people over 14.
Month
Day
Year
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Are you currently seeing a therapist?* This field is required.
YESNO
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Have you ever been diagnosed with a mental health problem?This information can help us match you with the right provider.
Share any prior diagnoses.
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Please list all prescription medications you are currently taking:* This field is required.
Write N/A if you do not take any prescription medications.
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Have you ever been to the hospital or emergency room for a mental health reason?* This field is required.
Please Select
Please Select
Never.
Yes, in the past year.
Yes, more than a year ago.
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Hospitalization Details
Why were you hospitalized?
Suicide attempt
Suicidal thoughts
Unusual or odd behavior
Psychosis
Eating disorder
Something else *
What were the approximate dates of your hospitalization(s)?
Dates
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I plan to cover services by:* This field is required.
Please Select
Please Select
Aetna
Blue Cross Blue Shield (Regence, Premera)
First Choice
Kaiser PPO
Moda
PacificSource
Providence
United/Optum
I will pay out-of-pocket
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We'll need a copy of your insurance card (if applicable) and your license:You can upload now or later through the portal. This helps us check your insurance benefits faster!
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Important Practice Policies

We cannot prescribe controlled medications in Washington due to telehealth restrictions. This includes medications used for ADHD (e.g. Adderall, Concerta, Vyvanse, Ritalin) or anxiety (e.g. Xanax, Ativan, Klonopin).

We do not complete FMLA, disability, or ESA paperwork for new patients.

We are not in-network with Medicaid and Medicare insurance plans. Due to federal restrictions, we generally cannot accept out of pocket payment from those insured by Medicaid and Medicare (including OHP, Apple Health, and Molina).
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Is there anything else we should know before scheduling your appointment?
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Please verify that you are human* This field is required.
Should be Empty:

Hospitalization Details

Important Practice Policies