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Inquiry form

A place to voice your needs

This form is:

For us to better understand your need and find the best services that can help you.
For you to share more details about .....

If you are

Unsure where to start your healing journey.
Need a support group but .......
Are part of the group of people who.......

Inquiry form

(Legal) First name

(Legal) Last name

Pronouns

(Preferred) First name

(Preferred) Last name

Phone number

May we leave a message?

Yes

What is your preferred method of contact (phone, email)

Relationship to client (self, partner, child, other)

I’m looking for:

Individual therapy

Relationship therapy

Nutrition counseling

Workshop

Retreat

Other

If you selected “other,” please share what you’re looking for.

Preferred provider (list all providers, please connect me to the provider best suited for my needs)

Are there specific identities or qualities you’re looking for in a provider?

Payment options

Insurance

Self-pay

If you selected “Insurance” above, please select your carrier:

Aetna

Blue Cross Blue Shield

Cigna (nutrition only)

First Choice

Kaiser HMO (Kaiser Core)

Kaiser PPO

Lifewise

Premera

Regence

Tricare West

Uniform Health Plan

f you selected “self-pay” above, please note that our full self-pay rate is $175 per session, and limited sliding scale spots are available. If you need financial assistance, please select the most sustainable option below:

Free resources

Under $100 (intern rate only)

$110

$125

$150

I would like support with (choose all that apply):

Disordered eating or eating disorders

Chronic dieting

Body distress

Fat liberation

Relationships (of any configuration)

Medical nutrition therapy

Intuitive eating

Medical astrology

Trauma or PTSD symptoms

Sex and sexuality

LGBTQIA+ focus

Neurodivergent focused therapy

Anxiety

Depression

Chronic illness

Grief

Meaning and spirituality

Other

Thanks, we will be in touch soon!

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Inquiry form A place to voice your needs

This form is:

If you are

Inquiry form

Stay updated with our offerings

Inquiry form

A place to voice your needs