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First Name

Last Name

Pronouns

A pronoun is a word that substitutes for your name. Examples include he, she, and they. We want to know what to call you when we get in touch so let us know your pronouns, if you feel comfortable doing so.

Phone*

Email*

I am interested in (select from the following):*

Individual Therapy
Couples Therapy
Family Therapy
Workplace Well-being
Other

What would you specifically like counseling to support you with?*

We are paneled with Pacific Source, Moda, and Trillium. Select which insurance you would like to use for services, if any. Note that we typically are not able to use insurance for couples counseling.

PacificSource
Moda
Trillium
Out-of-network (we do not submit for out-of-network, but we do provide superbills for your reimbursement)
Private pay
Other

Describe your typical availability.*

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Online counseling is available! We’d love to hear from you. Give us a call at 503.549.4714, or fill out this form. A counselor will contact you as soon as we can! (Your message will be encrypted for secure delivery.)

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