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New Patient Form
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New Patient Form

PMA providers are contracted with Regence and Premera. Patients who have other insurance companies may send in their statements to receive out-of-network benefits based on their plan.

We have openings for psychiatric services including medication management.

Please fill out the form in detail and we will get back to you via email with further instructions. Our providers are accepting patients on a case by case basis and endeavor to make sure they are a good fit for your needs. 

Name *
E-mail *
Phone Number *
Birth Date *
City and State of Residence *
PMA takes Premera, and Regence only. We do not bill Medicare or any MedAdvantage plans. *
If referred, please indicate by whom. *
Type of services desired *
Do you have a gender preference for your provider? *
Have you been hospitalized for a mental health issue in the past? *
If you have been hospitalized in the past please describe in detail *
Are you under a court order to see a mental health provider? *
Have you had any suicide attempts *
If you have suicide ideations please explain *
Do you engage in self harm? *
If you engage in self harm, please describe *
Do you need support with any substance over-use and or abuse? *
If you answered "Yes" please describe your current substance use status. *
Do you suffer from an eating disorder? *
If you suffer from an eating disorder please describe *
Are you switching from another provider or seeking services for the first time? *
If switching providers please explain the reason. *
List all medications you are currently taking. *
Who currently prescribes your medications? *
List Any and All Mental Health Diagnosis or Issues You Are Dealing With *
Please describe your past mental health treatments including any inpatient or partial inpatient services *
Describe the type of provider and services you desire *
Once submitted you will be place on our waiting list and contacted when there is availability. Currently the wait list spans over three months. Please acknowledge you will be on our wait list. *

From Our Doctors

"I view my relationships with my patients as an opportunity to work collaboratively to help them live the enriched life they desire." Read More

- Ashley Bouzis, M.D., Seattle, WA

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