Insurance Information Form

Book an Appointment

New clients are welcome, with urgent appointments available depending on situation. You’re always welcome to email or call, I'll do my best to respond promptly. I have over 20 years of bedside experience. I earned my Masters and Doctoral degrees from UW and am dual‑certified in Primary Care and Psychiatric Mental Health NP. I’ve cared for clients in high‑acuity settings, from pediatric homes at Madigan Army Hospital, Adult Family Homes, and competency restoration at Western State. I also help with everyday functional needs -ADHD eval, supportive work/school documentation, and guidance that keeps life moving forward.
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To know if you are using Medicare or Medicaid, check your insurance card: Medicare cards are red, white, and blue (often with "Medicare Health Insurance" at the top), while Medicaid cards are issued by your specific state and often feature state-specific branding. You may have both (dual-eligible) if you are 65+ or disabled with limited income.
Legal Full Name*

First NameLast Name
Email Address*
example@example.com
State
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Insurance Information

Please enter the correct information, and include photos of your insurance card.
Insurance Provider*
Member ID
Group ID
Date of Birth

MonthDayYear
Date
Policy or Member Number*
Upload Insurance Card (FRONT)*

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Upload Insurance Card (BACK)*

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Reason of Visit*
Schedule an Appointment

Current clinic hours for in‑person and telehealth visits are Wednesday–Saturday, 10:00 AM–6:00 PM, and additional times can be discussed depending on availability. Please share the days and times that work best for you:
Preferred Appointment Date and Time*
Should be Empty:

Book an Appointment