Let’s create a stronger community, together For further information about becoming a client, working with us for supervision, or trainings, please submit this form and we will get back to you. Name * First Name Last Name Email * Phone * (###) ### #### What insurance coverage do you have? Oregon Health Plan - Open Card PacificSource OHP/PacificSource Community Solutions Moda Kaiser Permanente Providence other Date of Birth MM DD YYYY What support or services are you looking for? * How did you hear about us? Any additional information we should know? We use an online Electronic Health Record with a client portal through a website called SimplePractice. May we use the information you provide to create portal access for you? This will allow you to provide us with more information. This portal complies with all relevant privacy laws related to mental health services. Yes No Thank you!If you requested clinical services, someone will be in contact with you soon to gather more information and schedule a consultation to determine best-fit. For all other inquiries, we will get back to your request in the order in which they were received.
