Contact us to get scheduled

Name

Date of Birth

Phone Number

Email

Insurance InsuranceCash PayAetnaBlue Cross of IdahoBPA EAPChamp VACigna/EvernorthCuralinc EAPFirst ChoiceGPAHumanaKaiserMagellanMedicaid (Idaho)MedicareMolina of IdahoNew Directions EAPOptumPacific SourcePremera Blue CrossRegence BCBS (Any State)TriCare WestTriWest/VAUHCVital EAPOther - Please include insurance in comments

Interested in Psychiatric Evaluation? Interested in Psychiatric Evaluation?YesNo

Interested in Medication Consultation Interested in Medication ConsultationYesNo

Open to Tele-Health? Open to Tele-Health?YesNo

Have you received a previous mental health diagnosis? Have you received a previous mental health diagnosis? Yes No

If yes, what diagnosis was given?

Are you currently on any medication? Are you currently on any medication? Yes No

If yes, what are you taking?

Briefly describe your goals and we will attempt to match you with the right practitioner

Preferred Office Preferred Office Coeur d'Alene Ponderay Telehealth Only

----------------------------- ----------------------------- I understand that completing this form does not guarantee services, and that MWRS will review my inquiry to determine appropriate clinician fit. I consent to being contacted by phone or email regarding my inquiry.