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Eastside Family Renewal Service |
Client FormsClients are required to fill out the basic forms below. Save the time you spend with your Practitioner talking about your goals, not your address and phone number! Bring your completed paperwork to your first session. |
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“Therapy is not inexpensive, but it isn’t necessarily out of reach either. I don’t make a lot but I was sure throwing tons of money away on quick mood fixes like movies and shopping. I’m so glad I figured that out finally. This saved my life. My quality of life!” - former client who received treatment for depression. |
Insurance?The Health Insurance Portability and Accountability Act (HIPAA) was enacted by the U.S. Congress in 1996 to protect your privacy. You will need to read and sign the HIPAA Privacy Agreement if you intend to use health insurance or a health benefits savings account for services.
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Contact us: |
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Forms |
Mail your check or money order to:Eastside Family Renewal Service Attn: Name of Practitioner Office at: Fern Life Center 710 Fifth Ave. NW Issaquah, WA 98027 |
Coordination of Care?With your permission we can receive copies of past and current health, education, and/or psychological records. This may help inform a more accurate case conceptualization, diagnosis and inform treatment. Download and print the following form to request that this information be shared with your Practitioner.
Authorization to Disclose Health Related Information
You can also request we talk to teachers, daycare providers, family members, friends, and past therapists to collect information for assessment purposes or to help attain treatment goals. Off-site client advocacy or consultations are available on a case-by-case basis. Ask your Practitioner regarding pricing and availability of these services. |
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We use 100% Recycled Paper for all of our forms, reports and client education materials. |
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425.223.6150 |