UpWell New Client Appointment Request

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

So you're ready to start feeling better? That's great news! The fastest way to secure an appointment is to complete this form so we can match you with the best provider and make sure we can meet your goals.

We have new patient appointments available within 1-2 weeks.

We DO NOT provide 1st time ADHD diagnosis, but can support those with previous diagnosis.

Privacy Policy: Our New Patient Form is HIPAA compliant (protects your information) and will never be shared with 3rd party. By providing my contact information to UpWell Psychiatry, I acknowledge and give my explicit consent to be contacted via email and/or SMS for the purposes of engaging in services. You may opt out at any time.

Full Name *

Email *

Phone Number *

Date of birth *

YYYY

Current state of residence (we can only see clients located in Oregon or Washington) *

Oregon

Washington

Other:

I am interested in working with: *

First Available

Shannon La Douce, PMHNP

Megan Sapp, PMHNP, CNM, FNP

Katharine Frissora, PMHNP

Kelly Aldinger, PMHNP, MSW

Carrie Anderson, PMHNP (Cash Pay / OON only at this time)

Clear form

Never submit passwords through Google Forms.

This form was created inside of UpWell Psychiatry, LLC. Report Abuse

Forms