Rising Resilient | SimplePractice

Who would be receiving care?

My partner and me

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

State

Select the state you live in

Administrative

Inquiry reason

A quick way for me to understand what you’re looking for so I can get you the right information.

I’m curious about your services I have questions about cost, insurance, or OON options I want to check your availability I’m trying to figure out if we’re a good fit I’d like to get started with therapy Other

Client Preferences

What days/times generally work best for you?

This helps me determine scheduling fit before we connect. General time frames are fine.

Limited to 600 characters

Do you prefer in-person sessions, telehealth, or either?

Telehealth is available for Oregon residents. In-person sessions are in West Linn, OR.

In-person Telehealth Hybrid

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.