Getting Started

Intake Questionnaire

Help us understand your needs so we can match you with the right clinician and get your care started as smoothly as possible.

New Client Intake Form

Please complete all fields to the best of your ability. Your information is kept strictly confidential and is used only to support your care.

Personal Information

Legal First Name (for insurance)

Legal Last Name (for insurance)

Preferred First Name (optional)

Preferred Last Name (optional)

Date of Birth

Preferred Pronouns (optional)

Sex

Male Female Non-Binary

Email Address

Phone Number

Street Address

City

State

Zip Code

Mental Health Background

How would you rate your current mental health?

1Poor 2Fair 3Okay 4Good 5Great

Have you been diagnosed with any mental health conditions?

Yes No

Please specify the condition(s)

Are you currently receiving any mental health treatment?

Yes No

Please describe your current treatment

What are your main concerns or issues you would like to address?

Have you ever had any involvement with the legal system or are currently on probation?

Yes No

Additional information or comments (optional)

Insurance & Scheduling

Insurance Company

Insurance Member ID

Session Preference

In Person Telehealth No Preference

Do you have a clinician preference? (optional)

Preferred days and times for sessions

Who can we thank for your referral? (optional)

Thank you, your intake form has been received! A member of our team will review your information and reach out within one to two business days to schedule your first appointment. If you need to speak with someone sooner, please call us at 541-390-4559.

What to Expect

Step 1, Submit This Form

Complete the questionnaire as thoroughly as you can. There are no right or wrong answers.

Step 2, We Review & Match

Our team reviews your responses and identifies the clinician who is the best fit for your needs.

Step 3, We Reach Out

Expect a call or email within 1 to 2 business days to schedule your first appointment.

Your Privacy Matters

Confidential

All information you share is protected under HIPAA and used only to support your care.

Questions?

541-390-4559
Hello@WillametteValley-bh.com

Need to speak with someone now?

If you are in crisis or need immediate support, please contact the 988 Suicide & Crisis Lifeline by calling or texting 988.