1. Name *

First Name

Last Name

3. State of Residence *

I am licensed to provide care in Illinois, Oregon, and Washington. Telehealth only at this time.

Illinois

Oregon

Washington

4. Phone *

(###)

###

####

6. Preferred Communication Method *

Phone

Email

7. How do you plan to pay for therapy? *

**Please note that I am no longer in network with Blue Cross Blue Shield.** I am able to provide superbills if you'd like to use out of network benefits. Call your insurance company directly for eligibility and benefit information.

Out of Pocket ($150 per 50-min individual session)

Aetna PPO

Cigna PPO

Out of Network Benefits

Other - please note in message

9. Please confirm having read and agreed to my policy regarding acute need/specialty areas of care below: *

My belief is that some acute and specialized needs are best addressed by services able to provide more support and wrap-around care than is available through a small private practice. This may mean seeking care via a practitioner with specialized experience, a group practice, behavioral health agency, substance use program, or IOP program with more staff/resources to support you. Clinical issues that fall under this umbrella include current suicidal thoughts, serious thoughts of suicide or an attempt in the last 6 months, active eating disorders, substance abuse as primary need for treatment, intimate partner violence. If you are currently experiencing any of the above, we are not able to begin a therapeutic relationship at this time.

I read and agree to the acute needs policy

10. I'm interested in: *

Please check all that apply.

Individual Therapy

EMDR Therapy

Clinical Supervision/Consultation

Other

12. Consultations are utilized to assess need, fit, and availability. Filling out this form and/or scheduling a consult is not a guarantee of treatment. Please note this is not constantly monitored and any crisis needs should be directed to 911 or your nearest emergency room. *

I understand.