Community, Connection, Counseling

Patient Forms

Release of Health Information Form (pdf)Download

Patient Bill of Rights (docx)Download

Patient HIPAA Notice of Privacy (pdf)Download

Clinic Notice of Privacy Practices (pdf)Download

General Patient Update Form (pdf)Download

Couple & Family New Patient Packet (pdf)Download

Group Counseling Contract (docx)Download

Adult (Age 18 and Older) Mental Health Packet (pdf)Download

Teen (Age 13-17) Mental Health Packet (pdf)Download

Child (Age 12 & Under) Mental Health Packet (pdf)Download

Each client will be sent a link via their email to access the appropriate forms that need to be electronically filled out and signed via DocuSign, a HIPAA compliant platform.

Sliding Scale Documents

Sliding Fee Discount Application (docx)

Download

Sliding Fee Discount Program (docx)

Download

Sliding Fee Discount Schedule (pdf)

Download

288 Martin St, Blaine, WA 98230

Phone (360)-788-4228

In Case of Emergency

If this is a life threatening emergency and you or someone you care about is in immediate danger, please CALL 911.

If you need someone to talk to now, please TEXT 988 for the Suicide & Crisis Lifeline.