Chrystal Nelthropp | SimplePractice

Chrystal Nelthropp Send Message

Your info

First name

Last name

Phone

Name you go by

Date of birth

Reason for care

What is the reason for seeking care?

Anxiety Depression Grief Relationship issues Substance use Trauma Other Perimenopause Menopause Hormone fluctuation

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply Currently experiencing domestic violence Currently experiencing active addiction or substance abuse concerns

If other, please describe.

Are you currently experiencing a mental health crisis, or have active safety concerns?

Limited to 600 characters

Administrative

Questions about care

Referral source

Enter how you were referred to Holistic Northwest

Driver's license upload

Do not upload sensitive financial information such as credit card information.

Are you located in Oregon, Washington, or other?

Oregon Washington Other

Session preference

Online (Telehealth) In-person in Manzanita Oregon

Billing & Payment

Payment method

How do you plan to pay?

Insurance details

In-network with MODA, Pacific Source, United Healthcare, Regence Blue Cross Blue Shield. Out of network with OHP or Medicare.

Limited to 600 characters

Client Preferences

Preferred appointment times

Hours: Monday - Thursday 9am to 5pm by appointment

Morning Afternoon Early evening

Are there any additional details not covered that you would like Holistic Northwest to know?

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.