Contact Form - NW Mind-Body Wellness

New Patients

Mental Health Contact Form

Please complete the form below prior to calling our office directly.

Thank you!

Name *

First

Last

Preferred 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 Insurance

Services Requested *

Therapy
Psychiatric Medication Management (In-Office visits only, Telehealth services not offered)

Preferred Location *

I am under the care of a mental health provider but I am looking to make a change:

I have been hospitalized in the last year for my mental health.

I 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:

Are you able to go up stairs? (In Salem, most of our offices are located upstairs, but accommodations can be made for downstairs visits.)

Any additional information that would assist us in understanding your problems or concerns (both mental health and physical health conditions):

Email *

Comment