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New Patient Form

New Patient?

PMA providers are contracted with Regence and Premera. Patients with other insurance companies may submit their statements to receive out-of-network benefits under their plan.

We have openings for psychiatric services, including medication management and medication management paired with ongoing psychotherapy.

Please fill out the form in detail for consideration. We review submissions in the order they are received. Once we get to your submission, we will follow up with a call or email to discuss the next steps. This can take up to two weeks. 

Submitting a form does not guarantee services. We select patients on a case-by-case basis when a good match is available. 

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If referred, please indicate by whom:

If you have been hospitalized in the past please describe in detail:

Explain the details around any suicide attempts or suicide ideations:

If you engage in self harm, please describe:

If you answered "Yes" please describe your current substance use status:

If you suffer from an eating disorder please describe:

If switching providers please explain the reason:

List all medications you are currently taking:

Who currently prescribes your medications?

List any and all mental health diagnosis or issues you are dealing with:

Please describe your past mental health treatments including any inpatient or partial inpatient services:

Describe the type of provider and services you desire: