Talking Twenties New Client Request

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Answering the following questions helps us get a better understanding of the services you are looking for. This form is HIPAA-compliant, meaning it maintains the privacy of your health information.

A few notes about our services:
- We offer services by telemedicine (video) appointment only.
Due to federal restrictions, we are unable to prescribe controlled medications via telemedicine (e.g. Adderall, Ritalin, Vyvanse, Xanax, Klonopin). If we find that these may be the right option for you, we can often coordinate with your primary care provider to prescribe.
- We do offer late afternoon/evening appointments, however we cannot ensure regular appointment availability at these times.

See our website for more information on appointment types and costs: https://talkingtwenties.com/services/

Email *

Full Name: *

Date of birth: *

YYYY

How may we contact you? *

Call

Text

Required

Phone Number

For what issues are you seeking care? *

Anxiety

Depression

Mood swings

Irritability/Anger

Poor focus

Pregnancy/postpartum

Trauma

Mood changes around period

Other:

Required

What type of care are you looking for? *

Medication

Therapy

Both therapy and medication

Not sure

Required

What are your goals in therapy or what would you like to get out of our work together?

Please list all current medications you are taking: *

Are you currently or have you recently been pregnant? *

Yes

Have you been hospitalized for a psychiatric reason? *

Yes, in the past 2 months.

Yes, longer than two months ago.

No.

Other:

How would you like to pay for services? *

I understand that Marisa Bell does not participate with my insurance plan. I will pay in full at the time of the appointment. I may try to get reimbursement from my insurance company if eligible.

I would like to use my Premera insurance benefits.

I would like to use my Lifewise insurance benefits.

I would like to use my Regence/Blue Cross Blue Shield benefits.

Marisa Bell cannot provide services to individuals with Medicaid health plans, even if attempting to pay for services out of pocket. This includes Apple health plan and OHP. *

I do not have a Medicaid health plan.

I have a Medicaid health plan.

Currently we can ONLY provide services to Washington and Oregon residents: *

I am a Washington resident.

I am an Oregon resident.

I live in another state.

Is there anything else you would like us to know?

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Talking Twenties. Report Abuse

Forms