Contact us.kookaburracommunity@gmail.comBeaverton, ORVancouver, WA Get Started Here Intake Form Name * First Name Last Name I Prefer to go by He She They Other Phone * So we can call you back during business hours (###) ### #### Email * Incase we cannot reach you on the phone What is your home zip code * What type of service are you looking for? * I am unsure Individual Therapy Couples Therapy Family Therapy What is your age If you are filling this form out on behalf of someone else, what is the age of the patient? What insurance do you have if any? Please note that we cannot guarantee we will be able to match you with a provider who is in network with your insurance. Please check below if you are willing to see a provider for private pay rates (typically $120 - $300 depending on the provider). Yes, I am willing to pay private rates. What appointment days work best with your schedule? Monday Tuesday Wednesday Thursday Friday Saturday What time of day works best for your schedule? Morning (7am - 12pm) Afternoon (12pm - 5pm) Evenings (5pm - 8pm) How did you hear about us? Google (Search Engine) Social Media Friend or Family Referral Health Care Referral Other Thank you!
