Talking Twenties

For your convenience, we provide all services exclusively by telehealth (video).
We can only provide mental health services to residents of Oregon or Washington. Coaching can be done from anywhere!

Thank you for your interest in Talking Twenties! The information below helps us understand if we are good match for your goals.

For more details on the services we offer and our providers, please visit our website.

Your information

First name

Last name

Email address

Phone number

Talking Twenties may contact me by:

Phone

Text

Your name

Your goals

What services are you looking for?

Medication

Therapy

Professional/Academic Coaching

Something else

Other current issues:

Please include any relevant issues you are facing so we can match you with the right provider.

Are you experiencing

Suicidal thoughts

Self-harm

Thoughts of harming others

Violence at home

None of the above

What is your due date?

When did you give birth?

What are your goals in therapy? What do you hope to get out of working together?

More details help us pair you with the right therapist.

Coaching goals

Please include what you hope to get out of working together.

Would you like a family member to be involved in your care?

Billing & Insurance

Scheduling & Appointments

Medications or Treatment

I will manage my treatment alone.

Your details

Date of birth

We are only able to see clients age 14 and up.

Unfortunately we can only see clients residing in Oregon and Washington at this time!

Please list ALL current medications:

Are you currently in therapy?

Yes No

Has a professional ever given you a mental health diagnosis?

Have you ever been to the hospital or emergency room for a mental health reason?

Yes No

Why were you hospitalized?

Suicide attempt

Suicidal thoughts

Unusual or odd Behavior

Mania

Psychosis

Eating disorder

Something else

Other reason for hospitalization

What were the approximate dates of your hospitalization(s)

Are you currently self-harming? When was the last time and frequency?

Have you ever attempted suicide?

Yes No

Approximate date of last suicide attempt

Insurance & Payment

Please upload a picture of the front and back of your insurance card.

Add file

Please upload a file

We'll need a copy of your license or identification

I'll upload now. I'll email to contact@talkingtwenties.com

Please upload a copy of your license or identification

Add file

Please upload a file

This person will receive billing-only access to the client portal to make payments.

This is okay with me. I would like to arrange another way to pay for care.

Important Practice Policies

We are unable to prescribe controlled medications in Washington due to telehealth restrictions. This includes medications used for ADHD (e.g. Adderall, Concerta, Vyvanse, Ritalin) or anxiety (e.g. Xanax, Ativan, Klonopin).
We do not complete FMLA, disability, or ESA paperwork to new patients.
We are not in-network with Medicaid and Medicare insurance plans. Due to federal restrictions, we also cannot accept out of pocket payment from those insured by Medicaid and Medicare (including OHP, Apple Health, and Molina).

I have read and understand with the policies stated above.

I agree. I have a question about a policy above.

What is your question?

Is there anything else we should know before scheduling your appointment?

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