Name
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First Name
Last Name
Pronouns
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Please check as many as apply
Email
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Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Which therapist are you interested in working with?
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Feel free to elaborate further in the comments section at the end of this form if you wish!
1. Available therapy appointments vary but include different slots Monday- Friday, with the first appt of the day beginning at 8:30am and the last appt beginning at 4pm. Will this work with your schedule?
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2. Do you have access to reliable wifi, a smart phone, and/or a place to safely meet via telehealth?
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All appointments are either via telehealth or outside/walking therapy at this time. We will provide you with a link to your appointment, so you do not have to be highly tech savvy but do need to have reliable wifi and a safe/private place to meet (even if electing to do outside/walking therapy, since sometimes circumstances will change). Some clients use smartphones, some use computers. Some have private rooms to meet in and others meet in their cars, for example, in order to have a confidential space to talk. We are open but want to make sure you have a plan for telehealth meetings.
3. Do you plan to pay out of pocket for appointments or do you have Columbia Pacific insurance (Oregon Health Plan's regional CCO), or a commercial PacificSource plan (not through OHP)?
*If you have another insurance that provides out of network care options, you can check with them, as you may be able to submit invoices for reimbursement of our sessions. Please see our FAQ section for more info. At this time, we are only able to submit billing to Columbia Pacific CCO, PacificSource Commercial, or to accept payment from private pay clients at the time of our appointments.
4. If you will be paying out of pocket for appointments, are you able to pay NCC's full fee of $175 for a 50 minute appt or do you need to discuss our sliding scale in order to make therapy accessible at this time?
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*We reserve a limited number of sliding scale spots and use the "green bottle model" in order to make therapy more accessible to more people. If this is something you would like to explore further, please let us know.
5. Has someone in your life recommended therapy? If so, who and why?
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6a. What are your reasons for seeking therapy at this time?
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6b. What are some goals you are hoping to work on together during therapy appointments?
7. Have you previously received or do you currently identify with any sort of mental health diagnoses? If so, what diagnoses and do you feel they fit?
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8. Are you taking any medications for mental health at this time? If so, what medications and how do you feel about them?
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9. Are you concerned at all about your relationship with substances? If so, are you currently seeking support for these concerns?
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Please note that we do not specialize in recovery. We are happy to support any work you may be doing but will refer you elsewhere if that is a primary reason you’re seeking therapy at this time.
10. Have you ever been in therapy before? If so, what did you like about it? What didn't you like about it?
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11. Do you have any cultural or other identities that are important for us to know about? If so, please tell us more.
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12. What do you do for self-care?
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13. Who or what do you consider to be supportive in your life at this time?
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14. Please confirm having read and agreed to our policy regarding acute need below
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If you are currently having serious thoughts of ending your life or have had serious suicidal thoughts or made attempts in the last 6 months, we are not able to begin a therapeutic relationship at this time. Our belief is that acute needs are best addressed by services able to provide more support and wrap-around care than is available through a small private practice. If you are in need of urgent care, please refer to the information provided at the top of this form or refer to our webpage for other referrals for wrap-around care.
15. Covid & Our Commitment to Public Health
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As public health is a core value of North Coast Connection, we take a firm stance regarding Covid safety and believe in taking necessary steps toward protecting ALL community members.
For the time being, all appointments will be conducted via telehealth or outside/walking therapy.
When it is safer to return to in-person services, we will continue doing our part in keeping all community members as safe as we can with ongoing risk mitigation efforts. We will additionally continue to offer telehealth appointments to assure that mental health support continues to be accessible to all of our clients.
We appreciate your understanding.
15. Is there anything else you feel is important for us to know at this time?
You made it through all of our questions! Thank you. Somebody will be in touch with you in about 7 days!
If you were referred to us, who referred you? (If you were not referred and found us via one of the other ways listed above, simply write N/A)
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