Spectrum Psychology & Wellness New Patient Pre-Screening Get started by filling out the form below! "*" indicates required fields Patient First Name* First Name Patient Last Name* Last Phone*Email* Date of Birth* Insurance Provider (e.g. Blue Cross Blue Shield)* Insurance ID Number/Policy Number* Is the potential client a minor?*Please SelectYesNoAre the biological parents residing together? Yes No Parent Name* Parent First Name Parent Last Name Parent Phone*Parent Email* Brief Reason for Coming In*Relationship Counseling Select this if you are coming in for a form of relationship counseling How many partners are coming in for relationship counseling?* 1 other than me 2 other other than me More than 2 others than me Partner Name* First Last Partner Phone*Partner Email* Partner Insurance Provider (e.g. Blue Cross Blue Shield)* Partner Insurance ID Number/Policy Number* Date of Birth* Partner 2 Name* First Last Partner 2 Phone*Partner 2 Email* Partner 2 Insurance Provider (e.g. Blue Cross Blue Shield)* Partner 2 Insurance ID Number/Policy Number* Date of Birth* You have selected 2 or more partners. Please contact the office directly.HiddenPlease Select Provider*Rebbeca Lahann, Psy.DRachel Jensen, Ph.DMonika Peterson, Ph.DLeslie O’Neill, Ph.DBryan Gaviria-Jimenez, Psy.DMercedes Anderson, Ph.DJeff Lahann, MBANo PreferencePlease Select Provider* Rebbeca Lahann, Psy.D Mireille Reece, Psy.D Monika Peterson, Ph.D Leslie O’Neill, Ph.D Bryan Gaviria-Jimenez, Psy.D Mercedes Anderson, Ph.D Indra Gonzalez, Psy.D Sarah Koop, LPC Rachel Jensen, Ph.D Jeff Lahann, MBA No Preference It may take some time to get you scheduled with your preferred provider. We are not a crisis care facility. If you feel you are in crisis and need to be seen urgently, please call 911 or 988, or call the EMPACT crisis hotline at 480-784-1500 for assistance. Please note, our office does not provide court ordered, alcohol or substance abuse or medication management services.