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CONTACT US
This Contact Form is for GENERAL INQUIRIES. If you are looking to schedule with a specific
Mental Health
Counselor
, & view what INSURANCE they accept, please click here:
OUR THERAPISTS
First name
*
Last name
*
Email
*
Phone
*
Pronouns & Preferred Name
*
Birthday
*
Month
Day
Year
Please select your payment option
I will be billing my INSURANCE
I will be paying OUT-OF-POCKET (cash/credit)
Insurance Payment Options:
*
HSA (Health Savings Account)
Blue Cross Blue Shield
Regence
MODA
Pacific Source
OPTUM
United Health Care
CareOregon
Jackson Care Connect (JCC)
Oregon Health Plan (OHP)
Other
What type of Therapy session are you seeking?
INDIVIDUAL
COUPLE'S THERAPY
Other
What Days & Times would you prefer to schedule therapy?
How did you hear about us?
*
Is there anything you would like to share regarding the therapy you are seeking?
*
Submit
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