Full Name *

Email *

Date of birth *

Phone *

What do you need help with?

Who would you like to see in the practice? *

Bridget Wells (Virtual, in person on a case by case basis). Available Mon-Fri.

Kiley Petencin (virtual only). Available Mon-Wed

Julie Allen (Virtual, in person on a case by case basis). Variable availability

Christine Kim (Virtual, in person on a case by case basis). Available Mon-Fri

No preference / First available

Do you prefer to be seen... *

Virtually

In-person - this means we come to you in your home or a place in the community of your choice

Hybrid - virtual and in-person

If you want to work with us virtually, do you have the ability to use video technology, either on your phone or a computer?

Yes

What days are you generally available? *

Monday

Tuesday

Wednesday

Thursday

Friday

How did you hear about us?

Psychology Today

TherapyDen

Medical Provider

Vocational Rehabilitation

Google Search

Counselor

Xcelerate Women

Other

Insurance Information

If you're not using insurance, just put N/A.

Do you plan to use insurance? *

Yes

Signed Referral Request **If you are using insurance, we will need a signed referral from your doctor. Would you like us to request the signed referral on your behalf? We will need you to sign an additional release if so.**

Yes

Insurance Company *

Note: Put "N/A" if you are NOT using health insurance If you are using vocational rehabilitation services, please insert the contact info for your voc rehab counselor in this space.

Primary Care Provider Contact Info (name, practice name) *If you are NOT using health insurance, please skip to the next step question. *

Note: To process your request faster, please contact your Dr. and have them fill out and send a referral form. Note that a counselor, psychologist, or social worker is not considered a prescriber in Oregon and we will need a referral from one of the providers on the referral form.

Member ID *

Note: Put "N/A" if you are NOT using health insurance.

Communication preferences

What is the best way to get in touch with you? *

Phone Call

Text Message

I agree to receive communications from Holistic Community Therapy using the contact information I provide here.

Your information will NEVER be sold, shared, or use for any reason other than to contact you directly and is stored in accordance with our HIPAA and Privacy Policy.

Contact Form Used

UTM Source