Contact Name * First Name Last Name Name you Go By Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Gender Man ( cisgender) Woman (cisgender) Agender Gender Fluid Gender Nonconforming Non-Binary Queer Trans Man Trans Woman Two-Spirit Other Prefer Not To Say State * Is There Anything Else You Want to Share? For example: what you'd like to focus on, insurance or payment questions, etc. Consent * By sending a message, you consent to being contacted by this practice via email, phone, voicemail, or text. By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). I Agree. Thank you! I’ll respond to your email as soon as possible, typically within 24 hours. If you are in crisis or need help immediately please reach out to one of the following crisis lines. Pierce County Crisis Line: 1-800-576-7764King County Crisis Line: 1-866-427-4747Kitsap County Crisis Line: 1-888-910-0416Crisis Text Line: Text HOME to 741741National Suicide Prevention Line: 1-800-273-TALK (8255)Perinatal Support Washington Warm Line: 1-888-404-7763If you are experiencing a life-threatening emergency, call 9-1-1 now.
