Your journey begins here.Once you complete this form, we will reach out to you within 24 hours. Name * First Name Last Name Email * What is your phone number? (###) ### #### What is your date of birth? MM DD YYYY What gender do you identify as? Male Female Non-binary Gender fluid Transgender Prefer not to say What state are you seeking services in? Oregon Washington What insurance provider do you use? *** NOTE: WE DO NOT ACCEPT MEDICARE OR MEDICAID *** Providence Cigna Aetna Regence Moda First Choice Kaiser Humana Pacific Source Premera Other Please note that we cannot guarantee we will be able to match you with a provider who is in network with your insurance. Please check below if you are willing to see a provider for private pay rates (typically $210 - $425 depending on the provider). Yes, I am willing to pay private rates No, I am not willing to pay private rates How did you hear about us? Instagram Insurance company Yelp Psychology Today Primary care provider Word of mouth Google search Why are you seeking our services? * Thank you!
