New Patients Mental Health Contact Form Please complete the form below prior to calling our office directly. Thank you! Please enable JavaScript in your browser to complete this form.Name *FirstLastPreferred Pronouns *Date of Birth *Phone Number *Street Address *City *State *Zip Code *Mailing Address (If different from physical address)Email *Insurance Company *ID # / Group # *Insurance Phone Number *Primary Insured (If not the patient) - Name and Date of Birth *Secondary InsuranceServices Requested *TherapyWe are currently evaluating our provider caseloads and unable to accept new patients for medication management services at this time. Our site will be updated as soon as we are able to resume scheduling for medication management needs.Preferred Location *SalemWilsonvilleI am under the care of a mental health provider but I am looking to make a change: YesNOI have been hospitalized in the last year for my mental health. YesNoI have been previously diagnosed with the following mental health conditions:I am taking the following mental health medications:Please check behaviors or symptoms that occur more often than you would like them to:Aggression / AngerAlcohol DependenceAnxiety / Panic AttacksDepressionDistractibilityEating DisorderElevated MoodFatigueHallucinations ImpulsivityIrritabilityLoneliness / WithdrawingPhobias / FearsSleep ProblemsThoughts of suicide or self-harmWorrying / HopelessnessStressors related to LGBTQ/ TransgenderAre you able to go up stairs? (In Salem, most of our offices are located upstairs, but accommodations can be made for downstairs visits.)YesNoThird ChoiceAny additional information that would assist us in understanding your problems or concerns (both mental health and physical health conditions):Email *PhoneSubmit
