First Name *

Last Name *

Preferred Name

We currently ask for full legal name

We recognize the identities you carry may differ from legal and insurance identification. However, to make sure we don't run into potential billing or admin issues down the road, please share your full legal name as it appears on your state ID or insurance card.

Phone *

Email *

Date of birth *

What's the Best Way to Contact You? *

Whom Are You Seeking Counseling For *

Would your like first availability or work with a specific clinician? *

Are you physically living in Washington currently? *

Yes

What is your Primary Insurance? *

We are in network with Premera, Regence, Ambetter, Coordinated Care and Aetna. Not all providers are able to accept every insurance listed, even though our practice may be listed as in-network.

Provide 3 times that you are available for first appointment *

I’m seeking services for: *

Are you currently receiving therapy services or psychiatric treatment? Have you in the past, whether related or unrelated to your current request?

Yes

Have you ever been diagnosed with an eating disorder? *

Yes

Risk of Self Harm *

Is there anything else you would like our therapists to know about you and why you are reaching out? Feel free to include as much as you like:

How did you hear about us?

Would you like to receive a quarterly newsletter?

Yes

Email Risk Acknowledgement and Use Consent *

I understand that the use of email and SMS text messages are inherently insecure and thus poses a risk to the security and confidentiality of my protected health information and I consent to Wayfinder Counseling therapists and/or office staff communicating with me via email or text message

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