Interest List MHNW

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Interest List MHNW

What is your name? *

What is your date of birth? *

YYYY

What type of insurance do you have? *

Pacific Source

MODA

United

Cigna

Medicare Part B

Oregon Health Plan

Cash Pay

Providence

Blue Cross Blue Shield

Other:

Required

Do you have Medicare Part B (please answer yes or no REGARDLESS of whether you also have other insurance) *

Yes

Why are you seeking psychiatric care (1-2 sentences please)

How did you find out about us (insurance website, referral, etc)? If you were referred please let us know who sent you!

What is your phone number?

Can we contact you by phone and identify ourselves as Mindful Health NW?

Yes, via phone or text

Yes, via phone only

Yes, via text only

Clear selection

What is your email address?

Can we contact you via email and identify ourselves as Mindful Health NW?

Yes

Clear selection

What type of care are you seeking? please check all you are open to. *

Psychiatric management (medications, diagnosis, brief therapeutic interventions)

Psychiatric management and regular psychotherapy

Consultation/1-2 visits only

Required

Please list all psychiatric medications you are currently taking. *

We are a small private practice that is unfortunately unable to provide urgent/emergent psychiatric care outside of normal business hours. Do you have a history of urgent/emergent psychiatric needs? *

Yes

If yes to the above, please provide details regarding instances of urgent/emergent psychiatric care over the past year:

We are equipped to manage some but not all substance use disorders. Do you have a history of substance use disorder(s)?* *

Yes

If yes to the above, please provide details

The safety of our patients and staff is paramount. Do you have a history of violent behavior?* *

Yes

If yes, please provide details.

I understand that submitting this inquiry does not constitute a doctor-patient relationship and that I am NOT guaranteed an appointment *

Yes, I understand.

I am not currently experiencing a psychiatric emergency, including but not limited to active suicidal or homicidal ideation, new onset psychosis or mania, or any other conditions that require urgent care (please proceed to the emergency room or call 911 if you are experiencing these symptoms). *

I agree

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