Groups Only Inquiry

DEMOGRAPHICS

Full Legal Name*

First Middle Last

Preferred Name:*

Pronoun:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:*

Date of Birth:*

Email Address:*

Insurance:*

CareOregon
Commercial
Private Pay

Which commercial insurance do you have?*

Please notes that we are only in-network with the listed commercial insurance companies. If you have another insurance provider, we will need to bill out network or provide you with a super bill.

I understand that I have selected private pay and will be responsible for the entire cost of services at the time of service.*

Yes
No

Therapy Services Intake: $175 Sessions: $155 Groups: $40 - or 6 for $192 Medication Management Intake: $200 Sessions: $100

Which insurance provider do you have?*

AT THIS TIME, WE ARE UNABLE TO PROCESS SECONDARY AND TERTIARY INSURANCE CLAIMS.

Insurance ID #:*

I certify the above is my primary insurance carrier. I understand that if it is not, I am responsible for the bill in its entirety.*

Yes
No

I understand that ITTC does not bill medicare as a primary or secondary.*

Yes
No

I understand that I am responsible for co-pays at the time of service. I understand that I am responsible for any deductibles and any other expenses not covered by my insurance due to denials or lapse in coverage.*

Yes
No

* A Card on file may be required for services to be rendered.

GROUP ONLY QUESTIONS

As an outpatient mental health clinic, our current contracts state that our office is not able to provide support for those who might be more appropriate for substance abuse treatment, those experiencing chronic suicidality or any other major risk factor that may require the use of a 24/7 crisis responder and/or care that is outside of our scope.

ALL CLIENTS WHO ARE NOT ENGAGED IN INDIVIDUAL THERAPY WITH ITTC OR BLOOM ARE REQUIRED TO HAVE A PRIMARY THERAPIST PRIOR TO ENGAGING IN GROUPS.

Do you currently have a primary mental health therapist?*

Yes
No

Please provide their name and contact information.

Primary diagnosis from referring/primary mental health provider:*

What group(s) are you interested in attending?

Are you actively engaged in any addictive behaviors?*

Yes
No

If yes, what and how often?

Are you currently on any psychiatric medication?*

Yes
No

We must conduct a mini mental health assessment session prior to new clients engaging in groups, this session is typically between 1-2 hours and will be conducted via zoom, please list your availability for this session.

How would you prefer to be contacted for follow up and intake scheduling?*

Email
Phone

May we leave a message?

Yes
No

Consent*

I agree to groups only policy

I understand that this information and inquiry is for groups only and will not result in individual services nor will it expedite my placement on the waitlist if I am waiting for individual services.

To obtain individual services I understand that I must complete the Intake Inquiry Form found on our website.

(971) 266-6910

hello@ittc.hush.com

DEMOGRAPHICS

GROUP ONLY QUESTIONS

ALL CLIENTS WHO ARE NOT ENGAGED IN INDIVIDUAL THERAPY WITH ITTC OR BLOOM ARE REQUIRED TO HAVE A PRIMARY THERAPIST PRIOR TO ENGAGING IN GROUPS.