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Complete the request form below and mail, email, or fax it to the office as noted below.

*By completing this paperwork, it does not guarantee that you will become a patient of Laurie Muhlbauer, PMHNP-BC.  This is to help determine the fit between the individual and provider.   

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Mail: Laurie Muhlbauer, PMHNP-BC at 4035 12th St Cutoff SE Ste 140, Salem, OR, 97302

Fax: Laurie Muhlbauer, PMHNP-BC at 855-541-6860. 

Email: LaMuhlbauer@protonmail.com

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                                                                                           Adult Intake Request Form

 

 

                                                                             Teen/Adolescent Intake Request Form

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For intakes:

Please, arrive on time.  If you are more than 5 minutes late you may be considered a “no show.” 

Intakes will not be rescheduled if the scheduled appointment is missed or a cancellation is provided less than 48 hours in advance.

Minors need to come with parents.