Welcome New ClientsPlease submit your intake form below.Step 1 of 911%Almost there 🙂Tell us a little bit more so to help us match you with a therapist that best fits your unique situationThis field is hidden when viewing the formYour Email Address* Patient Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code CAPTCHAWhat therapy services are you seeking?*I need help decidingCounseling/Talk Therapy for Children under 11Counseling/Talk Therapy for Teens ages 12-18Counseling/Talk Therapy for Adults age 19 and upCounseling/Talk Therapy for Relationships/CouplesCounseling/Talk Therapy for FamilyI do not want therapyDO I NEED THERAPY OR PSYCHIATRY? Therapy focuses on improving your emotional well being using talk therapy modalities, meeting weekly or bi-weekly with your clinician until your goals are met. Psychiatry focuses on improving mental health through a medical lens, similar to how you might talk to your primary care doctor about your overall physical well being. At a psychiatric appointment, you will learn about what options you have to make changes in your body chemistry using either lifestyle choices or medications. If you are not sure what service you need, our client care team will help you determine that during the registration process.Therapist(s) Preference*No PreferenceAlex ContradesAlison Mim MackAmanda RutledgeAmiee BurtoftAmy SchottensteinAndrea DavisAnn HusakBarbara GorhamBecka ShawBethany ThomasBrien WoodCarrie McCollochChelsey BuckhamConnor BurgessDea LuvonGabe GomezGenevieve DalenceGeoffrey FongHaley BoscoloJennifer OlsonJohn HallKatharine AndrewsLeah CantorNicholas BoswellNico KladisNicole Sadow-HasenbergQuinn WilliamsRue CvetovacTim RichardsonPsychiatric Services Requested*I don’t need psychiatric servicesPsychiatric Medication Evaluation and/or Medication Management for Child/TeenPsychiatric Medication Evaluation and/or Medication Management for AdultAdvanced Practice Registered Nurse (ARNP) Preference*No PreferenceGeoffrey FongTim RichardsonIn-Person or Virtual appointment?*No PreferenceIn PersonVirtualHybrid is okayWhat are you seeking support for? (choose all that apply)* Autism/Spectrum Disorders ADHD Anxiety Anger Management Addiction Career Stress Chronic Illness Depression DBT Eating Disorders EMDR Family Counseling Family of Origin Issues Grief & Loss Gender & Sexual Identity Infidelity Life Transitions LGBTQi+ Men's Issues Medical Issues Moms & Caregivers Mood Disorders Multicultural Concerns OCD/Panic Disorder Poly/Kink PTSD Parenting/Parent Coaching Play Therapy Relationship Counseling Stress Self-Esteem Self Harm Sex Therapy Somatic Symptoms Stress Management Substance Abuse Trauma Women's Issues/Infertility Work/Life BalancePlease tell us more about why you are seeking support*Do you hope to use your insurance?*I am flexible to use in or out of network servicesI need in-network options onlyI plan to pay out of pocket (will not use insurance)Paying out of pocket expands the options for which clinicians you can see, but we still do need to know what insurance you have. Primary Insurance Plan*PLEASE SELECT YOUR PLAN BELOWSelf-PayMedicareMedicaid/Apple HealthAnthem BCBSAetnaBCBS of IllinoisBCBS of TexasBCBS of CaliforniaBCBS other out of state planOther non-state BCBSBlue CrossBlue ShieldCignaFCH (First Choice Health)Kaiser PPOKaiser COREKaiser Out of State PlanLifewisePremeraRegenceRegence UniformMagellanPacific SourceSwedish/ProvidenceUHC (United Health Care)Value OptionsTricare3rd partyOtherI don’t knowIf other insurer, please provide plan name here*Primary Insurance ID*Primary Insurance Group Number*Name of Primary Insurance Holder* First Last Primary Insurance Holder's Relationship to Client*SelfSpouse of ClientParent to ClientPrimary Insurance Holder's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Primary Insurance Holder's Sex Assigned at Birth*MaleFemaleDo you have more than one insurance plan?*NoYes*If you have more than one insurance plan, you will need to call to confirm which has been assigned as your primary and which as secondary. If this is not done in advance, your insurance may reject the claims.Name of Secondary Insurance Plan*Do you have any current diagnosis?*NoYesPlease list your Current Diagnosis*Do you have a current provider (therapist or prescriber)?*I do not have a therapist or prescriberI do have a therapistI do have another prescriberI have bothName of current therapist*Name of current prescriber*In the last 10 years, have you ever had thoughts that you don’t want to live?*NoYesAre you having these thoughts currently?*Yes - currentlyNot now - but in the last weekNo - only in the pastHave you made any suicide attempts in the past?**NoYesIf you said yes to any of the above, please share more.*Please note, we don't provide crisis care as we don't have full-time staff or after-hours options, but we can provide referrals if we are unable to treat you. If you need immediate care, please call the Suicide and Crisis Lifeline at 9-8-8 or for local resources dial 2-1-1Is your therapy court mandated?*NoYesPlease describe in more detail*Is there legal involvement w/family (divorce, parenting plan etc)?*NoYesPlease describe in more detail*Do you currently drink more than 2-3 alcoholic beverages per day on a regular basis?*NoYesAnything else you want us to know to help make the best placement?How did you hear about us?*SelectGoogle/online searchPsychology TodayYelpFriendCounselor/Doctor (please name below so we can thank them)Insurance Plan - KaiserInsurance Plan - RegenceInsurance Plan - PremeraInsurance Plan - OtherNot listed herePlease tell us how you found our services if not listed aboveName of your Counselor/Doctor so we can thank them 🙂May we thank them for the referral Yes NoPlease note - per Washington State Law, in order for us to provide behavioral health services, you must be in the state of Washington at the time of service. (Please type "I agree" if you accept this legal requirement.)*X/TwitterThis field is for validation purposes and should be left unchanged. Existing ClientsClick the link below to access the patient portal.Patient Portal
