Required Forms - Printable
Providers Addendum to the Informed Consent:
- Art Tolentino, PhD, LMFT, MAC, CDP, SAP
- Loretta Crawford, MA, LMHC
- Kaj Kayij-Wint, LMFT, PhD Candidate
- Kelly Kimbel, MA, LMHC
- Mary Trokositz, MA, LMHC, CDP
- Mary Coacher, MA, LMHC
- Douglas Gemmell, MA, LMHC
- David Moeglein, MSW, LICSW
- Patricia "Pat" Beck, MA, LMHC
- Kris Vegvari, MA, LMHC, MAC
- Lisa Hanna, MA, LMHC
We cannot process your intake paperwork until we received all of the required forms and a copy of your insurance card and picture ID.
Please fax all the required forms and a copy of your photo ID and insurance card to (360) 539-1715 in Lacey or to (360) 846-1722 in Longview. Please do not email insurance cards or other confidential information as email is not a secure method of transmission. Once we have all forms and have verified your insurance coverage, we will call you to schedule an initial assessment.
Notice: Due to Washington health care laws, the ROI form should be completed by clients age 13 and up if a parent or other party will need to communicate with us about scheduling or other information.