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I’ll answer your questions and we can decide if I’m the right therapist for you. Complete this form and I’ll be back in touch via email within 2 business days.

Current client?

Click this link to access your client portal.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

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I am interested in...

EMDR Therapy Intensive

Individual Psychotherapy

I prefer...

In Person Sessions (Springfield, OR)

Telehealth Sessions (Virtual)

Either/Both

If you plan to use insurance for individual therapy, please provide the name of insurance company and your Member ID.

Note: I am in network with PacificSource Health Plans (commercial), PacificSource Community Solutions (Medicaid/OHP), Regence BlueCross BlueShield of Oregon, and Providence. If you plan to pay for services out of pocket, please write "Self Pay."

What would you like support with?

Note: Please do not include Personal Health Information in this form.

Please list the days/times you are available for sessions.

How did you hear about my services?

If a referral, please provide their name.

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