Talking Twenties New Request

1
First, we'll need some information about you
Client Name
Email
Phone Number
2
How may we contact you?* This field is required.
Text Message
Email
Phone Call
3
Thanks! Who is completing this form?* This field is required.
Please Select
Please Select
Myself
A friend or family member
A professional (referral)
4
Your Info* This field is required.Name of person filling out the form
First Name
Last Name
5
Referring Clinician Info* This field is required.
6
What are the main reasons you are looking for help?* This field is required.
7
How do you want help with those issues?* This field is required.
Prescription medication
Routine (weekly/biweekly) therapy
Brief therapy as part of routine medication visits
Someone to help me choose the best path!
8
Do you need a provider who:
Specializes in pregnancy/postpartum
Specializes in LGBTQIA+ mental health
Treats ADHD & can prescribe stimulant medication
N/A
Other
9
What are your goals for treatment? What do you hope to get out of working together?* This field is required.
10
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
Carly Hernandez Kadell
Marisa Bell
Nicole Ervin
11
Which state do you live in?* This field is required.We can only provide services to residents of Oregon or Washington.
Oregon
Washington
12
Birth Date* This field is required.We can only provide services to people over 14.
Month
Day
Year
13
Are you currently seeing a therapist?* This field is required.
YESNO
14
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.
15
Please list all prescription medications you are currently taking:* This field is required.
Write N/A if you do not take any prescription medications.
16
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.
17
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
18
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
19
We'll need a copy of your license and insurance card (if applicable). Would you like to upload that information now?
YESNO
20
Upload your license and insurance hereThis helps us check your insurance benefits faster!
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
Ok, you can email us that information later!
22
Would you like someone else to be involved in your care?* This field is required.
23
What is their info?* This field is required.This person will receive billing or scheduling-only access to our client portal.
24
Important Practice Policies

We have limited ability to prescribe controlled medications in Washington due to telehealth restrictions. This includes controlled 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).
25
Is there anything else we should know before scheduling your appointment?
Should be Empty:

Hospitalization Details

Ok, you can email us that information later!

Important Practice Policies