Dr. Sanderson and Associates Contact Us

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We are so glad you are reaching out. We will follow up with you within two business days.

If this is an emergency and you are in a mental health crisis, please call 503-291-9111.

The information you submit in this form is protected by our secure form system. If you would rather give this information over the phone you are welcome to call 971-264-0952 and we can help you out!

Your Name *

Your Pronouns

Do you have any accessibility needs for filling out this form?

Best Contact Email *

Best Contact Number *

What are you looking for: *

Individual therapy for me

Individual therapy for someone else

Group therapy for me

Group therapy for someone else

Other:

What are your top three mental health concerns right now? *

Do you have particular needs for your therapist (gender/nonbinary, specialties, available hours, telehealth/in person, anything else)? *

Are there therapies in particular you are hoping to try (For example, EMDR, IFS, CBT, DBT, Homework Assignments etc) *

We cannot guarantee any particular therapist will have openings at the time of interest, however, is there is a specific therapist you are interested in working with from our team? *

How did you hear about us? *

Website

Social Media (Facebook, Instagram, Twitter, Pinterest)

Google

Friend

Another Professional

Other:

If you are planning on using insurance, what insurance do you have? *

Aetna

Cigna (Evernorth)

Providence

Moda

BCBS Regence

Pacific Source (Uprise)

Reliant Behavioral Health (Uprise)

First Choice

MHN

Kaiser

HealthSmart EAP

Health Advocate EAP

M&S EAP

BHS EAP

No insurance (Paying out of Pocket)

Conventional Email Risk Acknowledgement and Use Request

You have a choice when it comes to how we communicate. Conventional Email (Gmail, Yahoo, Comcast etc) is inherently insecure. Additionally if you use a work email to communicate your boss or IT department may be able to read or know information you may not want them to know.

Know that I only use secure communication through Luxsci that covers my G-Suite program. When I email you it will be encrypted. But it may not be when you email me directly from your email program.

One of the two options below must be selected for me to follow up and communicate with you: *

I understand that conventional email is inherently insecure and therefore poses a risk to the privacy and security of my Protected health information. I accept these risks and consent to Dr. Sanderson and Associates communicating to my unsecured email with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment.

I only wish to be contacted via secure communications means, or at the phone number provided, until such time as I may elect to make a request for communication via non-secure means at a later date.

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