Name *

First Name

Last Name

Phone *

(###)

###

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I'm interested in services for: *

Myself

My child

Child's Name (if applicable)

First Name

Last Name

Please indicate which services you are interested in:

Individual Counseling

DBT Skills Group

OCD/Anxiety Group

OCD Assessments

Parent Coaching

Interested in a particular provider? *

Soonest Available

Rachel Dahl, LICSW

Dustin Ducharme, PhD

Michaela Hagerty-Koller, MA, LMHC

Haley Moutier, MA, LMHC

Robin Smith, MA, LMHC (current openings)

Leah Stoller, MA, LMHC

Ben Dobmeier, MA, LMHCA (current openings)

Negar Koore, MA, LMHCA (current openings)

A note regarding associate therapists: *

The Bellevue Center is strongly committed to addressing the shortage of mental health care providers in Washington State. As such, TBC trains a number of clinicians who are working towards independent licensure and practice, but who are still pre-licensure, “associate therapists.” Associate therapists:  Are supervised by senior clinicians  Are lower-fee for services ($150/session compared to $200-$300/session).  May have availability sooner than senior staff. Based on this information, are you open to working with an associate therapist?

Yes

No

Possibly open; would like more information

Concerns *

ADHD

Anxiety

Autism

Depression

Eating disorders

Emotional Regulation

Gender/sexuality

Learning disability

OCD

Parenting / Parent training

Perfectionism

Procrastination

Relationships/friendships

Self harm

Social skills

Substance use

Suicidality

Traumatic event(s)

Please review the following disclaimers before you submit your inquiry form. *

I understand that clincians associated with TBC are out-of-network providers. They will provide superbills patients can submit to insurance. Pro bono and sliding scale services depend on the clinician.

I acknowledge that electronic communication, including web forms and email, is limited in terms of privacy and may be intercepted by a third party. I also acknowledge that this electronic communication does not constitute a therapeutic relationship.