Intake Request Form

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.

INITIAL SCREENING QUESTIONS

These questions will help us match you with an appropriate clinician or refer you to another provider if we feel your needs might not be appropriate for the level of care we can provide.

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.

Our intake coordinator and therapist staff will determine if your case meets the threshold for the level of care we are able to provide. This may be determined during or after an initial intake session.

Are you currently or in the last 6 months, been engaged in mental health services?*

Yes
No

If yes, where?

How did you find ITTC?

Do you identify as having any physical disabilities? (this question is to be able to make accommodations before you arrive)

What are you hoping to address while attending ITTC? (General answers are just fine.)*

After reading the bios for our team members, is there a clinician you would prefer working with?

**this is not a guarantee as clinicians wait times vary

If the clinician(s) you identified are currently full, would you be open to a match made by our intake team?

Yes
No, I would rather wait.

please skip if you did not identify a clinician in the above question.

Do you have a gender preference for your clinician?*

Yes
No

What is your gender preference?*

Is there anything else you would like us to consider when making a match between you and a future provider?

**Clients requests for EMDR will be further assessed once paired with a primary assigned clinician

Are you actively engaged in any addictive behaviors?*

Yes
No

If yes, what and how often?

Are you actively engaged in restrictive or binge eating behaviors?*

Yes
No

If yes, what and how often?

What is your current housing situation?

Are you currently on any psychiatric medication?*

Yes
No

How many times have you been hospitalized in the last year?*

Sessions are 2 weeks a part, do you feel you are able to maintain between session without additional support from ITTC care providers?*

Yes
No

Please provide us with a brief description of your daily challenges:

What is your availability?

Which location are you interested in? (check all that apply)

Portland Office
Forest Grove Office
Telehealth

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

Email
Phone

May we leave a message?

Yes
No

Our wait list times vary based on availability and goodness of fit. Do you feel you are able to wait more than 14 days for a first appointment or would you prefer to receive referrals to other providers?*

I can wait
Please send me referrals instead

Do you wish remain on our inquiry list after receiving referrals?*

yes
no

Would you see a graduate student intern if it meant a substantially shorter wait?*

Yes
No

All student interns are supervised, mentored, and offered substantial amounts of training and support through our organization.

In response to the increasing concerns around COVID-19, we are conducting all individual sessions electronically including the intake session. Electronic session can be conducted by phone or video via Zoom.*

I am okay with electronic sessions.
Please contact me when in office sessions are available again.

(971) 266-6910

hello@ittc.hush.com

Please read our team bio’s prior to completing this form.

DEMOGRAPHICS

INITIAL SCREENING QUESTIONS