Name *

First Name

Last Name

Phone *

(###)

###

####

Telehealth *

Do you understand that all sessions are Telehealth

Yes, I understand

Do you live in Oregon? *

I have an Oregon license and can only see patients in Oregon

Yes

Session Fees *

While this consult is complimentary, all sessions beyond this are $175 and I am only in-network with Regnece Blue Cross and PacificSource. While I can provide you with a Superbill to submit for insurance reimbursement, you are responsible for contacting your insurance to discover what they will or will not cover. By checking this box, you understand that you are responsible for paying for your sessions out of pocket unless you are with one the in-network providers listed above.

Yes, I understand