Please read our referral criteria. This form is for Primary Care Providers and Psychotherapists. This is not a guarantee of treatment.
Thank you for taking the time to coordinate care for this patient. We will email the patient to let them know we received your referral.
Skycloud Admin
Evidence-based mental
healthcare at Skycloud
Do you prefer to register online or by phone?
I understand that only the patient or their legal guardian should complete this form.
I am the:
The potential patient, or their parent/guardian, must fill out this form. Identification will be requested during the process. If they are not available, please direct the potential patient to this page at a later time. Health care providers can find referral information here.
We are taking patients ages 13-17 with certain specified insurance panels in OR, WA, and UT. “You” in the following slides refers to the potential patient.
Are you seeking psychotherapy, medication management, or another evaluation type?
We are currently accepting new clients for psychiatric evaluations. Our psychotherapy caseload is full but you can contact us to learn more and join the waitlist.
Our psychotherapy caseload is full. Patients in OR, WA and UT can join our waitlist by clicking the button below.
Learn more about psychiatric evaluations, which can help you determine a treatment plan. Call us at 503-694-3391 or email admin@skycloudhealth.com with any questions.
Limitations of Skycloud:
Have you attempted suicide in the past?
When was your most recent suicide attempt?
Unfortunately we do not have clinicians who are able to treat you via telehealth at this time. Please contact clinic at (503) 694-3381 with questions and check our list of resources.
Have you ever been hospitalized in a psychiatric unit or stayed in a residential mental health facility?
When was your most recent hospitalization or stay in a residential mental health facility?
Where do you reside?
We are only offering services in Oregon, Washington, Utah, New Mexico, Arizona, and Minnesota at this time.
Are you currently prescribed a stimulant (e.g. Adderall, Ritalin) or benzodiazepine (e.g. Ativan, Xanax) and seeking to continue it?
Are you currently prescribed a stimulant (e.g. Adderall, Ritalin) or benzodiazepine (e.g. Ativan, Xanax) and seeking to continue it?
Are you currently prescribed a stimulant (e.g. Adderall, Ritalin) or benzodiazepine (e.g. Ativan, Xanax) and seeking to continue it?
Are you currently prescribed a stimulant (e.g. Adderall, Ritalin) or benzodiazepine (e.g. Ativan, Xanax) and seeking to continue it?
We prescribe controlled substance medications (i.e. stimulants, benzodiazepines) only to patients in OR, WA and UT with a required minimum once yearly in-office visit in Clackamas OR, Issaquah WA, Lehi UT, or Layton UT when clinically appropriate (please view our stimulant policy). It may be helpful to note that in our practice, we rarely use benzodiazepines (e.g. Xanax, Ativan, Klonopin). Contact admin@skycloudhealth.com with questions.
In-office visits are required once a year in Clackamas OR, Issaquah WA, Lehi UT, or Layton UT for patients who are prescribed controlled substances. Click “Okay” to continue.
We prescribe controlled substance medications (i.e. stimulants, benzodiazepines) only to patients in OR, WA and UT with a required minimum once yearly in-office visit in Clackamas OR, Issaquah WA, Lehi UT, or Layton UT when clinically appropriate (please view our stimulant policy). It may be helpful to note that in our practice, we rarely use benzodiazepines (e.g. Xanax, Ativan, Klonopin). Contact admin@skycloudhealth.com with questions.
In-office visits are required once a year in Clackamas OR, Issaquah WA, Lehi UT, or Layton UT for patients who are prescribed controlled substances. Click “Okay” to continue.
We do not prescribe stimulant, benzodiazepines, Suboxone, or other controlled substances in Minnesota. If you would still like to schedule, click Okay. To see other Resources, click “Resources.”
Which insurance plan do you have?
Which insurance plan do you have?
Which insurance plan do you have?
Which insurance plan do you have?
Which insurance plan do you have?
Which insurance plan do you have?
If your insurance was not listed, we may not be in your network. Please email billing@skycloudhealth.com to verify.
If your insurance was not listed, we may not be in your network. Please email billing@skycloudhealth.com to verify.
How old are you?
We do not have providers serving people under 18 at this time who accept your insurance. Email us for temporary self-pay options while our pediatric providers are in the credentialing process. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Our provider is in process of panelling with your insurance. You can see him at a discounted self pay rate until he is contracted. Click below to schedule.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*Note: All times are in Pacific Standard Time (PST).
Our providers will review your submission to determine if we are a good fit for your needs. Please submit the following required information for the potential patient (yourself or your child): insurance, age, current medications names and dosages. If the potential patient is taking a benzodiazepine, specify if they are looking to taper off of the medication. If the potential patient is a minor, please specify whether or not they have a history of self-harm. *It may be helpful to note that in our practice, we rarely use benzodiazepines (e.g., Ativan, Xanax, Klonopin).
Our providers will review your submission to determine if we are a good fit for your needs. Please submit the following required information for the potential patient (yourself or your child): insurance, age, current medications names and dosages. If the potential patient is taking a benzodiazepine, specify if they are looking to taper off of the medication. If the potential patient is a minor, please specify whether or not they have a history of self-harm. *It may be helpful to note that in our practice, we rarely use benzodiazepines (e.g., Ativan, Xanax, Klonopin).
Are you currently prescribed a stimulant (e.g. Adderall, Ritalin) or benzodiazepine (e.g. Ativan, Xanax) and seeking to continue it?
We do not prescribe stimulant, benzodiazepines, Suboxone, or other controlled substances in Arizona. If you would still like to schedule, click Okay. To see other Resources, click “Resources.”
Which insurance plan do you have?
If your insurance was not listed, we may not be in your network. Please email billing@skycloudhealth.com to verify.
We are accepting self-pay patients for psychotherapy in Oregon and Utah. Our provider is in process of credentialing with several insurances. We have a waitlist for clients in Washington.
We are accepting PacificSource, Aetna and self-pay patients for psychotherapy in Oregon and Utah. Our provider, Nat Day LCSW, is also in process of credentialing with other insurance panels - Cigna, BCBS, and Moda. Please provide your contact information for a 15 minute free consultation phone call.
Our psychotherapy waitlist is open for patients located in Oregon, Washington, and Utah with Cigna, Aetna, PacificSource, United, Moda, and self-pay pay sources only. The waitlist is currently closed for Regence (BCBS) and Providence insurance. Our psychotherapy providers treat ages 18-64. This waitlist is currently 6-12 months out, depending on age, state and insurance. Please provide the information requested below. Note: do not use this form in an emergency.
Los formularios de registración deben completarse dentro de las 24 horas posteriores a la reserva o la cita será cancelada. Los formularios tardan entre 15 y 20 minutos en completarse. Tenga a mano su método de pago, identificación estatal y tarjeta de seguro médico.
*Todos los horarios están en hora estándar del Pacífico (PST).
Proceed with online registration or by phone?
Phone Number: (503) 694-3381
Phone Hours: 3:00pm-6:30pm (PT) TWTh / 11am-2pm (PT) Sat and Sun
Register below for a phone call, or call our office number (503) 694-3381 ext. 2 to register. Please only request for a phone call for yourself.
Thanks for submitting this form! We will contact you during the specified times.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*Note: All times are in Pacific Standard Time (PST).
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Are you currently prescribed a stimulant (e.g. Adderall, Ritalin) or benzodiazepine (e.g. Ativan, Xanax) and seeking to continue it?
We do not prescribe stimulant, benzodiazepines, Suboxone, or other controlled substances in New Mexico. If you would still like to schedule, click Okay. To see other Resources, click “Resources.”
Which insurance plan do you have?
If your insurance was not listed, we may not be in your network. Please email billing@skycloudhealth.com to verify.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*Note: All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
We prescribe controlled substance medications (i.e. stimulants, benzodiazepines) only to patients in OR, WA and UT with a required minimum once yearly in-office visit in Clackamas OR, Issaquah WA, Lehi UT, or Layton UT when clinically appropriate (please view our stimulant policy). It may be helpful to note that in our practice, we rarely use benzodiazepines (e.g. Xanax, Ativan, Klonopin). Contact admin@skycloudhealth.com with questions.
In-office visits are required once a year in Clackamas OR, Issaquah WA, Lehi UT, or Layton UT for patients who are prescribed controlled substances. Click “Okay” to continue.
Which insurance plan do you have?
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Our providers will review your submission to determine if we are a good fit for your needs. Please submit the following required information for the potential patient (yourself or your child): insurance, age, current medications names and dosages. If the potential patient is taking a benzodiazepine, specify if they are looking to taper off of the medication. If the potential patient is a minor, please specify whether or not they have a history of self-harm. *It may be helpful to note that in our practice, we rarely use benzodiazepines (e.g., Ativan, Xanax, Klonopin).
How old are you?
We do not have providers serving people under 18 at this time who accept your insurance. Email us for temporary self-pay options while our pediatric providers are in the credentialing process. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*Note: All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
How old are you?
We do not have providers serving people under the age of 13 at this time. Here is a list of resources.
Due to federal laws that prevent us from seeing patients who are qualified for Medicare as self-pay patients without opting out of Medicare, we are unable to see patients who are over 65 at this time. Here is a list of resources.
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*All times are in Pacific Standard Time (PST).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*Note: All telehealth appointments are listed in Pacific Standard Time (PST). All in-person appointments in Utah are listed in Mountain Time (MT).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*Note: All telehealth appointments are listed in Pacific Standard Time (PST). All in-person appointments in Utah are listed in Mountain Time (MT).
Registration forms must be completed within 24 hours of booking or appointment will be cancelled. Forms take 15-20 minutes to complete. Please have your payment method, state ID and insurance card available.
*Note: All telehealth appointments are listed in Pacific Standard Time (PST). All in-person appointments in Utah are listed in Mountain Time (MT).
Your information is kept confidential and helps us ensure we can provide you with care. Assistance: 503-694-3381 | admin@skycloudhealth.com
If you are in a mental health crisis, do not use this form, call 988.
