About Us
Services
Insurance/Cost
Our Location
Contact Us
Employment

About Us
Services
Insurance/Cost
Our Location
Contact Us
Employment

Contact Us

Interested in working with a counselor?

Please fill out this secure request form and we will respond as soon as possible. You may also email info@northwestcounsel.com

Legal Name(Required)

As listed with insurance

First Last

Preferred Name

If applicable

First Last

Client's Date of Birth(Required)

MM slash DD slash YYYY

Email Address(Required)

If the email address is not the client's, please detail who it belongs to in the "notes" section below.

Phone Number(Required)

If the phone number is not the client's, please detail who it belongs to in the "notes" section below.

Your name and relation to client

If different from above

Reason(s) for counseling(Required)

Please select all that apply

Anxiety

Depression

Grief

Trauma

Couples Counseling

General Self Improvement

Other: (please detail this in the "notes" section below)

Select all counselors client is open to seeing(Required)

Please select all that apply

ANY COUNSELOR / NO PREFERNCE

Amberlyn Casperson

Angela Edwards (virtual only)

Angie Gomez Horta

Beth Mercer (virtual only)

Bryce Wilson

Isabel Huntsman

John Carlsen

Keali Nowak

Leia Shinsato

Michelle Baker

Mike Thomas

Nick Etherington

Piya Banerjee

Signe Wallerich-Neils

Stephanie D'Cruz

Taylor Johnson (virtual only)

Preference for in person visits or virtual visits(Required)

We will do our best to accommodate scheduling as requested.

In-Person

In-Person / Open to Virtual

Virtual

Virtual / Open to In-Person

No Preference

Regular availability for weekly or bi-weekly sessions

Please check ALL that apply as our afternoon and evening availability is very limited.
Sessions start on the hour and last approximately 55 minutes.

Days I am available:(Required)

You will select times of the day separately

Monday

Tuesday

Wednesday

Thursday

Friday

Times I am available on Mondays(Required)

Any time on this day

Morning (9AM-12PM)

Afternoon (1PM-3PM)

Evening (4PM-6PM)

Times I am available on Tuesdays(Required)

Any time on this day

Morning (9AM-12PM)

Afternoon (1PM-3PM)

Evening (4PM-6PM)

Times I am available on Wednesdays(Required)

Any time on this day

Morning (9AM-12PM)

Afternoon (1PM-3PM)

Evening (4PM-6PM)

Times I am available on Thursdays(Required)

Any time on this day

Morning (9AM-12PM)

Afternoon (1PM-3PM)

Evening (4PM-6PM)

Times I am available on Fridays(Required)

Any time on this day

Morning (9AM-12PM)

Afternoon (1PM-3PM)

Evening (4PM-6PM)

Insurance

Insurance Provider(Required)

**Please note that we are unable to accept State insurance or Premera at this time. Also, any insurance carriers not listed as a choice below will likely be considered out-of-network.**

Cigna

First Choice

Kaiser

Private pay / OOP

Regence / BlueCross BlueShield (Anthem, UMP, etc.)

Other

Insurance Card Upload

Please upload a photo of the front and back of your insurance card to have your inquiry expedited

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 6 MB, Max. files: 3.

Aspects of your identity

Please let us know any aspects of your identity (race, class, gender, sexuality, ability, spirituality, etc.) that feels important for you to share.

Notes/Additional Information

About Us Services Insurance/Cost Our Location Contact Us Employment Privacy Policy

Schedule Your Appointment

253-446-7176 info@northwestcounsel.com
5620 112th St. E; Suite 215 – Puyallup, WA 98373

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