New Client Inquiry Form | Relief Mental Health

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First Name

Have you been hospitalized for your mental health in the last 12 months?

Yes

Last Name

Are you currently feeling suicidal? *

Yes

What is your City and State?

What is your age?

Check all you are seeking:

In office appointments only

Telehealth appointments only

In office and/or Telehealth appointments

Psych Evaluation / Assessment

Medication Management

Seeking counseling only

Are you currently on mental health medicaiton(s)? Which medication(s)? If not, please put N/A below

Who is your insurance carrier? Is your insurance through an employer?

If you have not already, please call your insurance carrier to be sure Relief Mental Health Consultants is in network with your health plan.

Cell Phone

By checking submit, I (you) agree to periodic automated or blast sms text messages on my mobile number from Relief Mental Health. Message & Data rates may apply. Message frequency varies. Text Stop or Quit to cancel at any time.

I accept terms & conditions

Thank you for your submission. We look forward to speaking with you. If you have not received a response within 48 business hours please call 855-704-2004.

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You can reach us at 855-704-2004

Our fax number is 503-386-3366

Office Hours:

Monday - Thursday: By Appointment

Friday & Saturday Closed

Sunday: By Appointment

Medication refill requests can take up to 7 business days. Some medication require an appointment with your provider prior to a refill.

If you are experiencing a mental health or medical emergency please go to the nearest emergency room or call 911!

National Crisis Line: 1-866-4CRISIS

Suicide Hotline: 988

TrevorLifeline 866-488-7386

LOCATIONS

Oregon

205 SE Spokane St., Suite 300

Portland, OR 97202

Texas

2000 East Lamar Blvd, Suite 600

Arlington, TX 76006

Washington

401 Broadway

Tacoma, WA

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