Silver Valley Interest Form
This is not a waitlist; rather, this is an interest list for when we are accepting clients in the Silver Valley. If you have any questions please contact us at info@westwindclnic.com or by calling (208) 261-1158.
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date of Birth
If child, Parent/Guardian name
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Do you prefer a Male of Female therapist?
*
Male
Female
Either
How do you want to attend your appointment?
*
Virtually
In Person
Either
What Insurance do you have?
*
Medicaid
Blue Cross Blue Shield
Regence
Aetna
Cigna
Other
Submit
Should be Empty: