• WELCOME
    Thank you for your interest in becoming a patient at Phoenix Rising Midlife Health Clinic.

    This Readiness & Alignment Screening is the first step in becoming a patient. It helps both you and our team determine whether our model of care is likely to be a good mutual fit.

    Our clinic is intentionally designed around partnership, prevention, healthy aging, and long-term health. The screening typically takes 10–15 minutes to complete.

    If your responses suggest there may be a good mutual fit, we'll invite you to schedule a Professional Consultation to discuss your goals, answer your questions, and determine together whether we'd like to move forward.

    If it doesn't appear our clinic is the right fit for your needs, we'll let you know honestly so you can pursue the care that's most appropriate for you.

    We appreciate the time you've taken to complete this screening and look forward to learning more about you.

    — Phoenix Rising Midlife Health Clinic


    BEFORE YOU BEGIN
    Please answer each question as honestly as possible. There are no "right" or "wrong" answers. Your responses simply help us understand your goals, expectations, and whether our approach is likely to be a good fit.


    WHY DO WE USE PHOENIX?
    After you submit this screening, your responses are first evaluated using our structured Readiness & Alignment process. If your responses indicate that our care model may be a good mutual fit, Phoenix, our clinical AI assistant, organizes and summarizes your information for our healthcare team before your consultation.

    Phoenix does not decide who becomes a patient or make medical decisions. All decisions regarding patient acceptance, diagnosis, treatment, and ongoing medical care are made by a licensed healthcare professional.

    We believe technology should support—not replace—the relationship between patients and their healthcare team. By reducing administrative work, Phoenix allows us to spend more time focused on the people we serve.

  • Tell Us About Yourself

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Which best describes your current stage of life? Select all that apply.*
  • Who Can We Thank For Referring You?*

  • What Are You Looking For?

  • Which areas are you hoping to improve or receive support with? (Select all that apply.)*

  • Understanding our Care Model

    Team-Based Care & Financial Structure
  • Phoenix Rising provides coordinated, team-based care, but services are not bundled into a single membership fee. The Primary Care membership covers Primary Care services only. Health coaching, psychiatric care, the Healthspan Assessment, and services provided by other healthcare professionals are not included in the Primary Care membership and are billed separately. Payment arrangements vary: Health Coaching has its own separate membership and published pricing. Psychiatric services provided by our PMHNP are billed to insurance. Your financial responsibility depends on your insurance benefits, deductible, copay, coinsurance, and other plan terms. The Healthspan Assessment is provided by an independent, cash-based physical therapy practice that establishes its own fees. Other specialists may bill insurance or charge patients directly, depending on the provider. Patients are encouraged to confirm current fees and applicable insurance benefits directly with the provider and their insurance plan. Do you understand that team-based care does not mean that all recommended services are included in the Primary Care membership?*

  • Required Healthspan Assessment
  • If your healthcare team believes that working with another healthcare professional (such as a mental health provider, health coach, physical therapist, dietitian, or specialist) would improve your care or help you make progress toward your health goals, would you be willing to participate?*
  • As part of our healthy-aging approach, patients complete a comprehensive Healthspan Assessment with our independent physical therapy partner in Turner, Oregon, during the new-patient intake process and annually thereafter. The assessment may evaluate strength, mobility, balance, and cardiovascular fitness, and your primary care provider uses the results to help guide your personalized care plan. The assessment requires a separate appointment, is not included in the Primary Care membership, and is billed separately by the cash-based physical therapy practice at its current rate. Do you understand and agree to complete the Healthspan Assessment in Turner during the new-patient intake process and annually thereafter?*

  • Clinical Approach & Expectations
  • Which statement best reflects your approach to improving your health?*
  • Which statement best reflects your expectations about healthy aging?*

  • How Our Clinic Works

    Office Operations
  • I understand that Phoenix Rising Midlife Clinic does not provide urgent care services. If you need urgent medical care, you will need to use urgent care or the emergency department when appropriate.*
  • I understand that Phoenix Rising follows the Salem-Keizer School District calendar for planned office closures, including holidays, inclement weather, and scheduled breaks.*

  • Partnership & Readiness

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  • Mental Health & Clinical Support

  • Have you ever experienced significant childhood adversity, trauma, abuse, neglect, or household dysfunction?*
  • Primary Care at Phoenix Rising does not replace specialized trauma treatment. If your healthcare team believes that trauma-focused or other mental health care would support your health and progress, would you be willing to work with a licensed mental health professional outside of Primary Care?*
  • Do you currently have, or are you currently being evaluated or treated for, an eating disorder involving significant food restriction, purging, or binge-and-purge behaviors—for example, anorexia nervosa, atypical anorexia, bulimia nervosa, or a similar condition?*
  • Have you ever been diagnosed with or treated for an eating disorder involving restriction, purging, or binge-and-purge behaviors?*
  • If eating disorder symptoms returned, or if a healthcare professional recommended further evaluation for possible eating disorder symptoms, would you be willing to work with an eating disorder specialist?*

  • Final Acknowledgement

  • Should be Empty: