Next Step:Please complete this Scheduling Form to help us understand your specific needs and to know which therapist to connect you with. Scheduling Form Patient Name * First Name Last Name Patient Date of Birth * Phone * If patient is under 18, this must be the Parent/Guardian's phone number (###) ### #### Email * If patient is under 18, this must be the Parent/Guardian's email Parent/Guardian Name Required only if patient is under 18 First Name Last Name How can we help you? * Counseling / Therapy A Comprehensive Assessment Other reason Briefly explain what led you to seek our services * If you're seeking an assessment, what is your primary reason? ADHD Autism Learning Disabilities Psychological or Behavioral Difficulties What is your "PRIMARY" Insurance Provider? * No Insurance Aetna Cigna Premera Blue Cross Regence BlueCross BlueShield (Please read our "fees & insurance" page) Anthem (Please read our "fees & insurance" page) Which time frames work for you to see a therapist on weekdays? 7am-11am (More availability during these hours) 11am-3pm (More availability during these hours) 3pm-8pm Preferred office location * Sammamish Office / In Person Online Video / Telehealth No Preference If there is a therapist that you would you prefer to see, please select from this list No preference Dr. Diane Shin (Assessments only) Nathan Shin, MA Cale Smart, MA Dr. Nicole Lemos Jon Leong, MA Ciara dela Cuesta, MA Tessa Trosvig, MA Kristin Moore, MA Stephanie Strand, MA Lesley-Rose Gutter, MA Dr. Bob Smith Dr. Cheryl D'Ettorre Dr. Steph Regus Dr. Colleen Gorman How did you hear about us? * Web search / Our website Google Business Profile/Google Maps PsychologyToday.com Care Solace A therapist or provider (Please write in below) A clinic or hospital (Please write in below) Using the “Find a Doctor” or “Provider Directory” in my insurance portal A friend, acquaintance or family member I am a previous client Social Media (Please write in below) Other (Please write in below) How did you hear about us? (Continued)
