Secure Contact Form

PLEASE NOTE: I am not accepting any new clients at this time. I do not keep a waitlist.

Secure Contact Form

General Contact Form (please don't use this form for interest in therapy services)

First name

Last name

Email address

Phone number

Message

** Please note that I will respond to all inquiries from potential clients via secure e-mail. You will be asked to create a password to view the e-mail. I will respond within 5 business days.

Please do not use this form if you are having an emergency. Instead, please call 911 or Linn County Mental Health Crisis at 1-800-304-7468.

Therapy Interest Form

Please fill out the following information so that I can get a better sense of whether I'm able to offer you services. I will respond to your request via secure e-mail.

Please note that completing this form does not begin or guarantee a therapeutic relationship.

First name

Last name

Email address

Phone number

Gender identity and/or pronouns

Age

Message

Are you seeking telehealth therapy? Please note: I am only providing online teletherapy at this time

Yes No

Are you seeking individual therapy? Please note: I do not provide couples therapy, family therapy, or evaluation services at this time

Yes No

Do you have health insurance?

Yes No

Which health insurance do you have?

Are you located in Oregon?

Yes No

What is your general availability for scheduling? Are there specific days and times you are not available?

Please briefly describe why you're seeking therapy.

How did you hear about me?

Any additional information you'd like to share?

** Please note that I will respond to all inquiries via secure e-mail. You will be asked to create a password to view the e-mail. I will respond within 5 business days.

Please do not use this form if you are having an emergency. Instead, please call 911 or Linn County Mental Health Crisis at 1-800-304-7468.

Your information will be encrypted.

Secure Contact Form

PLEASE NOTE: I am not accepting any new clients at this time. I do not keep a waitlist.

Secure Contact Form

PLEASE NOTE: I am not accepting any new clients at this time. I do not keep a waitlist.

Renée Bockheim, Ph.D.

Licensed Psychologist