Let's start your journey here.

What's your first name? *

Last Name? *

Who is seeking therapy? *

Myself

Couple

Child

Partner First Name *

Partner Last Name *

Partner Email *

Partner's Phone Number *

How old is the child? *

Child's First Name *

Child's Last Name *

Child's DOB *

Please note: In Washington State, teens ages 13–17 can consent to their own mental health care and have rights regarding their own records. To make sure we can communicate directly with your teen, their phone number and email are required.

Teen's Phone Number *

Teen's Email *

Please make sure to provide both parents information in this contact form. This is required to be accepted for children's therapy.

Parent 2 First Name *

Parent 2 Last Name *

Do you have Insurance? *

Insurance Provider *

Who's the primary insurance holder? *

Primary Insurance Holder Date of Birth *

Preferred Office Location *

Kirkland

Bellevue

Telehealth

Reason for Counseling

Please do not submit any Protected Health Information (PHI).

By checking this box, I consent to receive non-marketing text messages from Eastside Counseling Center about therapy and health related appointments. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking the box, I agree to the HIPAA COMPLIANCE & NOTICE OF PRIVACY PRACTICES provided by Eastside Counseling Center. I understand that the information provided in this form will be used by the Company to create a secure patient portal account for each individual, and to send appointment-related paperwork, forms, and communications through the secure portal.

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