New Client Appointment Request Please complete all the fields below and select "submit," when complete. We will respond by email within 48 business hours, so please check your spam folder if you have not heard from us within that time. 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.
