If you hope to use your insurance to cover couples, family, or relationship therapy, please provide the insurance information for the person who will be billed. Parents and guardians completing this form on behalf of a minor should use their child's information. Note: we are NOT in network with CareOregon/Healthshare, Jackson Care Connect, & Columbia Pacific CCO)
Upload a photo of your insurance card
If you plan to pay out of pocket, indicate that here. Providing this information helps us prepare for your screening. We make every effort to verify insurance eligibility and coverage prior to the screening call.
For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.