Contact Us

5440 SW Westgate Dr, Suite #210, Portland, Oregon 97221
Phone: (503) 966-1556 | Fax: (503) 716-4699
Email us: info@mindtreeholisticcounseling.com

Client Forms

If you are new to therapy, please be sure to fill out the following forms, and bring them to your first session. This will help ease you into therapy, and allow as much time as possible to be spent focusing on you.

Adult Intake

Authorization To Email Receipts

Consent For Telehealth Consultation

Contact information

Copy of Release of Information Consent

Credit Card Authorization

Good Faith Estimate Acknowledgement form

Informed Consent for Psychotherapy

Notice of Privacy Practices

Opt Out Insurance Form

Policy for Treating a Child of Divorced, Separated, or Unmarried Parents

Practice Policies

Psychotherapy - Insurance form

Psychotherapy Consent for Treatment - Private pay

Standard Intake Questionnaire Template - Psychotherapy

Amy Hughes - Good Faith Estimate Form

Kathy Link - Good Faith Estimate

Kathy Link - Professional Disclosure statement

Louise Davis - Good Faith Estimate Form

Marena Pasarelli - Good faith Estimate

Melika Watson - Good Faith Estimate

Melika Watson - Professional disclosure statement

Monica Fuentes Carbonetto - Good Faith Estimate

If you feel that you would like to collaborate your session with another provider, simply fill out the following form.

Release of Information Consent

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MindTree Holistic Counseling & Wellness Center LLC

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.