Name *

First Name

Last Name

I am interested in: *

Please select any that apply to you.

Mental Health Counseling

Therapy for Artists/Creatives

Trauma Therapy

Psychedelic integration

Which state do you live in? *

Oregon

Washington

Payment Type *

Please select one. If selecting insurance, please provide your date of birth and Policy # in the message field below.

Private Pay

OR Medicaid Plan

Pacific Source

Aetna

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