Pre-Screening Form

First Name:

Last Name:

Email:

Phone:

Street Address:

City:

Region/State/Province:

How did you hear about us?

Google Social Media Friend Family Doctor Mental Health Provider SUD Provider School

Reason for referral:

Insurance Information:

Aetna Blue Cross Blue Sheild Premera Tricare Cigna Medicaid Kaiser Regence

What Sessions do you plan on participating in?

Individual Therapy Family Therapy Marriage/Couple Therapy Art Group Therapy Medication Management Medication Assisted Treatment Nutritional Therapy IV Therapy Spa Therapy

Chronic Medical History:

Do you have any question or comments?