New Client Inquiry
Interested in learning more about our services? Sign up for a consultation.
Full legal name (for billing and insurance information):
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First Name
Last Name
Name you wish to use:
Date of Birth (M/D/YYYY)
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Month
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Day
Year
Date
Email address
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Preferred contact method
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Text
Email
Phone
What insurance do you have? (Self-pay option is available)
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Please Select
Providence Health Plan
PacificSource (Commercial)
Blue Cross Blue Shield of Oregon / Regence
Aetna
Cigna
Moda Health
Self-Pay
If your insurance is not listed here, please enter it in the other field. For a complete listing of accepted insurance plans, visit https://headwell.org/fees.
Insurance Member ID
What are you interested in learning more about? (Please check all that apply)
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Explore Mental Health, in-person or telehealth options
Medication Management
Lifestyle Counseling
QbCheck ADHD Testing
Are you also interested in Spravato and Ketamine services?
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Yes
No
Gender
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Male
Female
Transgender
Non-binary
Prefer not to say
Other
Reason for visit. Is there more you would like to tell us about why you are inquiring today?
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How did you hear about us?
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If you were referred to us by a medical professional, please enter their name and practice affiliation here.
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