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Working with Amanda
Billing and Fees
New Patients
Contact

Services
Working with Amanda
Billing and Fees
New Patients
Contact

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New Patient Request Form

Start by completing the New Patient Request Form. I'll get back to you by phone or email about availability and scheduling.

Or, take a few moments to learn more about my style and how we'll work together.

Your Name*
First
Age*
Please enter a number from 0 to 200.
Email*
Phone*
Preferred method of contact?*
Occupation*
Student? Plumber? Entrepreneur?
Do you have a family doctor or primary care physician?*
- Yes
- No
Who?*
How did you hear about Amanda?*
Can you commit to weekly one-hour sessions for the next 1-2 months?*
- Yes
- No
Can you commit to sessions during daytime hours (8-5)?*
- Yes
- No
Your insurance provider*
- Private
- Out of pocket
- Medicare/OHP
Who is your private insurance provider?*
I'm not currently accepting patients using Medicare or Oregon Health Plan. However, I've provided some trusted resources to help you find the care you need.
If you weren’t stuck feeling fatigue, depression, and stress, what would you be doing more of in life that you love and enjoy?*
If we spent one month working together, what changes in your life would need to happen for you to feel like your time and energy with me were worth it?*
What issues are you facing?*
Use the "other" option for anything you don't see here
- General stress/anxiety
- Grief and loss
- Depression
- Post-traumatic stress
- Childhood trauma
- Relationship issues
- Eating issues, appetite
- Body image
- Problems in school
- Problems at work
- Sleep, fatigue, and energy
- Holistic health and wellness
- Medical / health problems
- Bipolar disorder, I or II
- Personality disorders
- Substance abuse issues
- Marriage issues
- Other
*
In your own words, describe the top 3 problems in your life you’d like help with*
What medications are you taking?*
How are you feeling about your current medication?*
Are you interested in therapy alone, medication alone, or therapy and meds together?*
This form is a request to work with Amanda. The information provided is so she can get back to you about her availability for potential new clients. This form is not an agreement to assume psychiatric care or informed consent for treatment.*
This form is a request to work with Amanda. The information provided is so she can get back to you about her availability for potential new clients. This form is not an agreement to assume psychiatric care or informed consent for treatment.
- I agree
Comments
This field is for validation purposes and should be left unchanged.

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Working with Amanda
Services
New Patient Request
Billing and Fees
Resources
Contact