If you are interested in scheduling couples therapy, please fill out the information below and someone will be in contact within the next 24 business hours.

Primary Partner's Legal First Name *

Primary Partner's Legal Last Name *

Primary Partner's Preferred First Name

Primary Partner's Date of Birth

Primary Partner's Legal Gender (for insurance verification purposes) *

Primary Partner's Phone Number *

Primary Partner's Email Address *

Secondary Partner's Legal First Name *

Secondary Partner's Legal Last Name *

Secondary Partner's Preferred First Name

Secondary Partner Date of Birth *

Secondary Partner's Legal Gender (for insurance verification purposes) *

Secondary Partner Phone Number *

Secondary Partner's Email Address *

Primary Insurance Provider *

Who is the primary subscriber for the insurance policy (first and last name please)? The primary subscriber is the person who has the insurance through their employer. *

Primary Subscriber's Legal Gender (for insurance verification purposes) *

What is the primary subscriber's date of birth? *

Primary subscriber's employer? *

Your relationship to the subscriber? *

Member/Subscriber ID # AND Prefix (including all letters & numbers). If you do not have insurance and will be self pay, please type SELF PAY. *

Insurance Group ID # *

Do you have a Secondary Insurance Policy you would like to submit? *

Secondary Insurance Provider (if applicable)

Secondary Member/Subscriber ID # (including all letters & numbers) ?

Secondary Insurance Group ID #

Secondary Subscriber's Name

Secondary Subscriber's Date of Birth

Secondary subscriber's employer?

Our private-pay/out-of-pocket rate is $165 for the intake session and $150 per 55 minute session that follows. In the event that we are not contracted with your insurance carrier, or, you do not have insurance and will be self pay, are you comfortable to move forward with scheduling based on our rates? *

Are you planning to use an EAP through your employer? *Please note: If you are planning to use an EAP, we can not move forward with scheduling without all of the following requested info.

If yes, which company is your EAP through?

How many sessions have been approved?

Authorization Number?

Phone Number for EAP program?

Are you both currently living/residing in WA state? *

How did you hear about us? *

Please select your primary reason for seeking therapy: *

Select additional reasons for seeking therapy below (check all that apply)

Which quality is most important to you in a therapist?

We offer both in-person and tele-health appointments. Do you have a strong preference for one or the other? *

What is your preferred method of contact? *

If a phone call is your preferred method of contact, what are the best times for us to reach out to you?

8:30am-11am

11am-2pm

2pm-4:30pm

4:30pm-6pm

** Our clinician's schedules tend to be fuller on weeknights, as this is the most common request for session times. *Please provide as many options as possible that could work for your schedule, or include ongoing availability in the additional information section at the bottom of this form. The more options we receive from you, the more options we will have to get you started with a provider that is a good fit.

What Days and Times are You Typically Available? Please provide as much detail as possible on your availability.

Is there a clinician you are interested in working with?

Is there anything else you'd like us to know? (Please also include any additional details on availability here)

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