Appointment Request

Send us a message  and we’ll get back to you shortly.

Name:*

Pronouns:*

Legal First & Last Name (what it says on your insurance):*

Phone*

Email*

Birthday*

Insurance (CareOregon, Healthshare, etc. ):*

Insurance Number:*

How did you hear about others*

Bridge City Family Medical

Google

CREDN

Registered Dietician

Dr. Katie Picksworth

Psychology Today

Other:

What are you looking for support with and when did it begin to impact you? Any reasons for starting therapy now?*

We typically schedule clients for the same time each week, please check ALL days that you may be available for appointments:*

Monday Morning

Monday Afternoon

Tuesday Morning

Tuesday Afternoon

Wednesday Morning

Wednesday Afternoon

Thursday Morning

Thursday Afternoon

Friday Morning

Friday Afternoon

Can be available most days/times

I prefer:*

Telehealth appointments

In-person appointments

No preference- either options works for me

I consent to Hello Me staff contacting me via email to set up free 10 minute consultation call

I understand that Hello Me will be outreaching with a private number for consultation call

Visit Us

Address

Tillamook Building

Suite 270

2105 NE Cesar E Chavez Blvd

Portland, OR 97212

Contact: info@hellometherapy.com | Phone: 503-836-8836 | Fax: 503-836-8144

2105 NE Cesar E Chavez Blvd, Suite 270, Portland, OR 97212

The information on this website is for general information purposes only. Nothing on this site should be taken as healthcare advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute, an healthcare professional-patient relationship. We do our best to keep information accurate and up to date, however mistakes do happen, and we cannot make guarantees regarding the accuracy of our information. We are not liable for any information on this website or your reliance upon it.
Information on your rights and our responsibilities.

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Appointment Request

Send us a message and we’ll get back to you shortly.

Visit Us

Address

Send us a message  and we’ll get back to you shortly.