PDF Forms for Intake Appointment

Insurance Forms

Please choose the one applicable to you based on your insurance type.
If you have primary private insurance and secondary state insurance, please complete the Medicaid form only.
Financial Form – Cash Pay
Financial Form – Medicaid
Financial Form – Private Insurance

Intake Packet

Please choose the intake packet applicable to you based on your concern (Bloom/Pride) OR age (Child/Teen/Adult).
If couples or family therapy, please have each participant complete an intake packet.
Intake Packet – Bloom (Pregnancy, Postpartum, or Infertility – any age)
Intake Packet – Pride (LGBTQ+ – any age)
Intake Packet – Child (Ages 3-12)
Intake Packet – Teen (Ages 13-17)
Intake Packet – Adult (Ages 18+)

Assignment of Benefits

Assignment of Benefits

Telehealth Consent Form

TeleHealth Consent Form

call: 253.460.7248
email: info@integratedtherapynw.com
fax: 253.564.4409
3560 Bridgeport Way W
Suite 2-C
University Place, WA 98466