New Client Questionnaire Name * First Name Last Name Email * Phone Number * (###) ### #### Can we leave a message? * Yes No What's the best way for our Client Care Coordinator to contact you? * Email Phone Both Date of Birth * Are you, or the identified client, a minor? * Yes No Pronouns Gender for Insurance Billing Gender according to your insurance benefit Best Days to Schedule Therapy Sessions: * Mon Tues Wed Thurs Fri Ideal Time of Day to Schedule Therapy Sessions: Mornings tend to be the most available, and evenings are typically in high demand. Mornings Afternoons Evenings Insurance Payer * We are ONLY in-network with Pacific Source Commercial & Pacific Source Oregon Health Plan. Member ID Number: * Reasons for Seeking Therapy: * Therapist Preference: See "Our Team" for more details. Marginalized/ Oppressed Identities You are welcome. to share any details about intersecting identities that will be relevant when working with your therapist. Ex. BIPOC/ mixed race/ethnic background, LGBTQIA+, Gender Identity, Neurodivergence, Disability, Religion/ Spirituality, Class, Nation. of Origin, Age, and more. Do you have a previous mental health diagnosis? * In the past 2 years, have you experienced suicidal thoughts, or made threats or attempts at suicide? * Yes No Have you ever been hospitalized or received intensive care services for mental health conditions? * Yes No Do you or your loved ones have any concerns about your use of alcohol, drugs, or other substances? Yes No Do you have any other concerns regarding your safety at this time? * If so, then please describe: Do you have any accessibility needs that we should know about prior to your first appointment? * Thank you for completing this form! We look forward to connecting with you soon.
