Take a minute to write an introduction that is short, sweet, and to the point.

Request Consultation

CURRENT patients can book an appointment on the Patient portal.

PLEASE UNDERSTAND that due to the volume of requests, only those requests that can be accepted will receive a response. We see as many people as we can safely treat. (click button to understand)

Submission of this form does not create a provider-patient relationship. If there is a fit between your needs and the providers' clinical capabilities, you will be sent an email with available appointments. *

PLEASE UNDERSTAND that due to the volume of requests, only those requests that can be accepted will receive a response. We see as many people as we can safely treat.

Name

First Name

Last Name

Age

Phone

(###)

###

####

City (Serving only Washington State)

Method of Payment *

Chief Concerns (Indicate all that apply) *

Alcohol use disorder

Anxiety/Worry/Panic

Depression

Bipolar Disorder/Mania

Substance Use Disorder (what substance)?

Trauma/PTSD

Opiate Use Disorder

Other

Additional Information