Consultation Request Form

Emily L. Shiraishi, Psy.D., LLC

Please correct the errors described below.

Emergency Assistance

Please do not use this form in an emergency. If you are experiencing an emergency, please dial 911 or go to the nearest Emergency Room.

National Crisis Phone Line: 988
National Crisis Text Line: "Home" to 741-741

Please note that my practice is currently full and I have a waitlist for new patients.

First name

Last name

Preferred Name

Pronouns

Birth date

Phone number

It is okay to leave a voicemail regarding our meeting at this phone number?

Yes No

Email address

What do you want to work on in therapy?

What are you looking for in a therapist?

What questions would you like to have answered at our consultation?

I live in Hawaii, Oregon, or Washington, and therefore am eligible for these services.

I will be in Hawaii during our consultation. I will be in Oregon during our consultation. I will be in Washington during our consultation.

I prefer to consult by

Video call*

Please email me a video link to the email address I listed above. *I will email you from an encrypted email system called Hushmail, which will you require you to sign in to view emails.

Phone call

I have reviewed the privacy policies at www.emilyshiraishi.com/privacy-policy.

I understand that a consultation does not constitute a therapeutic relationship.

I understand that Emily L. Shiraishi, Psy.D. is in-network with some but not all insurance plans. It is my responsibility to check my benefits with my insurance company, as benefits vary widely even for in-network plans.

I would like some assistance or clarification on the use of the following payment methods:

HSA/FSA Accounts

Regence/BCBS/Anthem Insurance Benefits

PacificSource Insurance Benefits

Out-of-network Insurance Benefits

I would like to upload a copy of my benefit card to receive additional assistance: https://hushforms.com/dremilyshiraishi-secure-file-transfer

Dates and times I am available for a 15-minute consultation (Please specify which time zone):

How did you hear about my services?

Psychology Today Website Family or friend Healthcare provider Other

Your information will be encrypted.

Emergency Assistance

Please do not use this form in an emergency. If you are experiencing an emergency, please dial 911 or go to the nearest Emergency Room.

National Crisis Phone Line: 988
National Crisis Text Line: "Home" to 741-741

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