New Client Questionnaire

Please correct the errors described below.

Contact Information

This form is to get established on the wait list for mental and/or behavioral health services at Integrated Therapy Services NW. PLEASE NOTE: Estimated wait times vary depending on insurance, concerns, provider preferences, and availability. Once the form is submitted, our office will email you within a few business days to confirm receipt.

Insurance Information

    Please upload a file
      Please upload a file

      Reason for Seeking Services

      If you selected "Other," please explain. Any information provided helps therapists determine if their experience and credentials match what you are looking for.

      Current Concerns

      Kids Under 18 Years Old

      ITS is required to abide by legal parenting plans, guardianship documentation, restraining orders, and related legal documents. We are required to receive consent from any adult with decision-making ability for non-emergency medical treatment for children under 13 years old (RCW 71.34.530), and for children under 18 who are not attending counseling voluntarily (RCW 71.34.650).

        Please upload a file


        Availability - What days or times generally work best for scheduling appointments?
        Our office hours are Monday - Friday, 8 AM - 7 PM.

        Please note, afternoon and evening times are the most highly demanded and will likely result in a longer wait time.

        In order to have a Telehealth appointment, the client must be physically located in the state of Washington due to provider licensure.

        ITS DISCLAIMER: In-person appointments may increase your risk of contracting COVID-19. Therapy rooms are being sanitized in between every session. Selecting "In-Person" appointments does not limit you from using telehealth services in the future and may be set up at any time.

        Your information will be encrypted.