New Client Appointment Request Please complete all the fields below and select "submit," when complete. If you'd prefer to complete your inquiry by phone, please call us at 541-216-4034. Name * First Name Last Name Phone * (###) ### #### Permission to leave a voicemail: * Yes No Email * Permission to email you: * Yes No Cite, State you live * Your age (or age of client) * Insurance Carrier: * If there is not a clinician available that works with your insurance, are you interested in discussing a sliding scale, private pay option? * Yes No I'm not sure Is there anything we should know about you and what you're looking prior to our first consultation? * What types of services are you interested in? (Check all that apply) * Individual Counseling Couples/Marriage Therapy Family Therapy Group Counseling Would you prefer in-person or telehealth appointments * In-Person Telehealth No preference What is your general availability for appointments? * Thank you for submitting a New Client Appointment Request. One of our staff members will return your inquiry as soon as possible.
