[] 1 Step 1 Mental Health Form Let's get started Therapists Amanda LaCombe, LMFT, LPC and Nicole Estrada, LMFT are accepting patients on a limited basis. Please call (503) 586-0383 before you fill out the form if you would like to establish care with one of these providers. Patient Name Date of Birthyour full name Phone Numberyour full name Best time to contactyour full name What is your current insurance? Policy Holder's Nameyour full name Policy Holder's DOB:your full name Member ID #your full name Group #your full name Insurance ID numberyour full name Are you expecting any changes in your insurance in the next six months?more details0 / Name of your current employer?your full name Do you need to be seen immediately?more details0 / Which provider are you wanting to establish care with?Select An Option (THERAPIST)Nicole Estrada, LMFTAmanda Lacombe LMFT, LPC Please list any previous mental health diagnosis:more details0 / Please list all current medications including any you are taking for mental health:more details0 / How did you hear about our clinic? Please list the best contact number for you:your full name Can we leave a voice message on the above phone number?your full name Languagepick one!Select An OptionEnglishFrenchSpanish Submit Form Previous Next powered by FormCraft
