Become a Patient

1. Are you looking for an ND to provide general naturopathic or primary care? *

Yes

No

2. Do you live in the State of Oregon? *

Yes

No

3. Are you scheduling for someone besides yourself? *

Yes

No

4. Do you plan to use health insurance, or pay with cash? *

Insurance

Cash

5. Are you seeking mental health counseling? *

(Also sometimes called therapy, talk therapy, or psychotherapy)

Yes

No

6. Are you seeking a formal mental health diagnosis? *

Yes

No

Unsure

7. Are you currently taking, or interested in starting to take, any of the following controlled medications? *

No

Benzodiazepines like Xanax or Ativan or Nonbenzodiazepine drugs like Ambien or Lunesta

Stimulant Medications like Adderall or Ritalin or Vyvanse

Opioid pain medications like Vicodin or Oxycontin

Unsure

Legal name *

First Name

Last Name

Preferred name

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Sex assigned at birth *

Female

Male

Phone *

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