New Client Inquiry Form
Please fill-out the below form to meet with one of our practitioners and we will quickly work to get you scheduled at your desired time. 

If you have any questions or if you prefer to book over the phone, please call the office at 971.202.0677.

We look forward to working together!   
Sign in to Google to save your progress. Learn more
Who is Submitting this Booking Request *
Required
If Submitting for Someone Else, Please List Your Name and Relationship 
Client's First & Last Name *
Phone number *
Email *
Client's Date of Birth *
MM
/
DD
/
YYYY
Address for Billing *
Primary Insurance *
Primary Insurance ID
Secondary Insurance
Secondary Insurance ID *
If you are a dependent (Spouse/Partner/Child), list first and last name and date of birth of the primary insurance subscriber for the Primary & Secondary Insurance information listed above.  *
What is the best method to contact you? *
Required
What are the best times to contact you? *

  *
Required
Aside from any checked topics above, is there anything else you would like your counselor to help you with in your work together? *
Is there anything else that you would like to share with the counselor or that the counselor should know as they start to work with you?
IF 15 YEARS OLD OR YOUNGER: If Separated/Divorced, please list the Parent/Guardian who has legal custody.
IF 15 YEARS OLD OR YOUNGER: Who is the client living with?
IF 15 YEARS OLD OR YOUNGER: Who will be navigating appointments, billing needs & questions?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pacific Center for Mind and Health. Report Abuse
Google Forms