Request appointment | Sprout Therapy PDX

What kind of therapy are you looking for?

Please note: we suggest you have your insurance card handy and plan to complete this form in one sitting. On some mobile browsers, switching between tabs can refresh the page. We encourage you to provide short responses if completing on mobile so the form does not time out! Reach out to our Intake Coordinator directly if you're having trouble: intakes@sprouttherapypdx.com or (971) 319-4827. We are NOT in network with CareOregon/Healthshare, Jackson Care Connect, or Columbia Pacific CCO.

Individual Therapy: For an adult Individual Therapy: For a teen (13-17 years old) Individual therapy: For a child (5-12 years old) Couples or Relationship Therapy - If you'd like to use your insurance for couples or family therapy, the person who's insurance you plan to use should complete this form. You can learn more about using insurance for couples and family therapy on our website. Family Therapy Medication Management Group Therapy

What brings you in?

A few sentences is plenty. We'll go deeper on the call.

Limited to 600 characters

Have you been to therapy before? (If seeking medication management, have you worked with a prescriber before)?

If yes, have you ever been given a mental health diagnosis?

Limited to 600 characters

Is there anything we should know about the type of services you are seeking or any preferences or requirements you have for your provider?

For example: are you looking for a therapist with a shared lived experience or identity to you, or someone trained in any specific approaches or therapy modalities.

Are you interested in accessing or learning more about any of the following supports?

Selecting options does not commit you to services or guarantee availability.

Individual therapy only Medication management with a psychiatric prescriber only Medication management with a psychiatric prescriber, in addition to therapy Case management – help navigating resources, systems, and practical barriers Peer support – mentorship and support grounded in shared lived experiences with mental health treatment and recovery Therapy groups – skill-based, process-oriented, or identity-affirming groups Not sure, open to discussing

Have you ever been hospitalized or treated at a higher level of care for a mental health condition?

Yes No

Do you or your loved ones have concerns about your use of alcohol, recreational drugs, or other substances?

Yes No Not sure

Any accessibility needs for the call or first appointment?

If yes, please explain.

Anything else you'd like us to know?

If you are completing this form on behalf of someone else, please provide your name and contact information below:

I understand this form is for screening purposes only and does not establish care. You will only become a client after completing a full intake assessment and being formally assigned to a clinician. Participation in the screening does not guarantee availability of services. I consent to being contacted regarding the information provided.

There is no charge for the screening call. If you are covered by Oregon Health Plan (OHP/Medicaid), OHP may be billed for this screening service. Information shared during the screening will be documented in your clinical record and protected under applicable privacy laws.

I consent.

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