Northwest Counseling Services

Getting started is easy! Fill out this form. Once this form is reviewed and insurance is verified, we will set up a consultation to make sure Northwest Counseling’s Services is a good fit for what you need. At this time, you may fill out new client paperwork and meet your therapist and schedule your first session. Consultations are free and usually take 15 minutes. Consultations can be done over the phone or in-person. Please note, consultations do not guarantee a spot and cannot be used for counseling or crisis. You must establish care prior to being seen.

All medical referrals can be faxed to (208) 719-0011

Name

First Name

Last Name

Phone

(###)

###

####

What services are you interested in?

Individual Therapy

Couples Therapy

Empower Teen

Mental Health Evaluations

Are you looking for in-person or telehealth?

Please list insurance company or self pay

We currently only take Magellan/Medicaid, Blue Cross, Champ VA, Self-Pay, Premera.

Insurance Number including letters before number (If you are self-pay put 000)

Message (Briefly describe current symptoms and reasons for seeking services).

Authorization:

I authorize Northwest Counseling's Services PLLC to use and exchange personal information on this form to verify insurance eligibility. I have requested, received and reviewed Northwest Counseling Services HIPPA and Protected Health Information Policy, or declined and understand how my information will be used and give consent. Please state, Yes to authorization or No to authorization.

Northwest Counseling Services

Your Healing Journey

Northwest Counseling Services PLLC