New Client Inquiry Form | Relief Mental Health

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First Name

Last Name

Insurance company:

Have you been hospitalized in the last 12 months?

No

Yes

Are you currently feeling suicidal?

No

Yes

1. If you answered yes to any question, please elaborate. 2. What insurance do you have? 3. What city & state do you live in?

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.

Cell Phone

Email

I accept terms & conditions

Thanks for submitting!

You can reach us at 855-704-2004

Our fax number is 503-386-3366

Office Hours:

Monday - Thursday: By Appointment

Friday - Closed

Saturday and Sunday: By Appointment

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

Sheila - Clinic Manager

JD - Certified Medical Assistant

Serving Clients in Oregon and Texas

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