Name *

First Name

Last Name

Phone *

(###)

###

####

Have you ever been diagnosed by a mental health professional? *

Yes

No

Do you currently have health insurance? *

Yes, I have Kaiser NW

Yes, I have BCBS Premera

No, I don't have insurance

Are you a veteran or first responder?

Yes

No

Where do you live? *

Washington

Oregon

Check here if you live in Cowlitz county

Do you prefer a male or female provider?

Female

Male

No Preference