Inquiry for Therapy Services

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Bird Weaver Solutions is a safe, trauma engaged, welcoming service provider.

In fact, we will celebrate you. The real you(s).

Please complete this form to apply to my waitlist. Neither of us is committed to services by your submission of this form, this form is to hold your place in line should an opening occur.

At my next opening, the assessment rate is $500.00, the session rate is $250.00 after the required assessment. While we are happy to provide you with all required documentation, we do not interact with insurance, that will be your responsibility.

You will receive a confirmation email from this form, please save it to demonstrate your submission. We will not be able

Please be aware that you must physically be in the State of Oregon to receive therapeutic services.

Email *

First Name *

Last Name *

Type of therapy you'd like, select all that apply

Individual Therapy for an Adult

Partnership Therapy (couples+ welcome)

Family Therapy, Adults Only

Family Therapy, Children included (individual sessions with the child will occur with this option)

Group Therapy, Trauma Focused please be aware that this is online only

Required

Why are you seeking services at this time?

What are your top two concerns? Top three if you are a partnership or family.

How did you hear about me? *

What appeals to you about the services I provide? *

Are you interested in participating in research? Your Identifying information remains absolutely confidential. *

Yes

I understand that Bird Weaver Solutions, LLC does not participate on insurance panels and does not bill insurance for services. I understand payment is due at or prior to time of services.

Yes

I acknowledge that I have viewed the complete video(s) on this page and read the accompanying information. I understand that my information will be added to a waitlist and this form is not an agreement to provide or participate in services. I agree to be contacted by email to arrange for a consultation if services are appropriate.

Yes

I also consent for this website to collect this information consistent with this website's privacy policy.

Yes

Send me a copy of my responses.

Submit

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