Top Image
Home
Clinical Services
New Patient
patient questionnair
spacedivider
cancellation policy
spacedivider
practice_policy
spacedivider
authorization to exchange healthcare information
spacedivider
referral form
spacedivider
patient consent form
spacedivider
demographic information
spacedivider
privacy policy
spacedivider
fee schedule
spacedivider
Patient Journals
Seminars & Workshops
Consulting
Bookstore
Books for teens and parents
spacedivider
Books for clinicians
spacedivider
Resources & Links
NLM
spacedivider
AMA Adolescent Health Link
spacedivider
Medscape
spacedivider
SupportAlliance
spacedivider
About Clinic
Office Location
spacedivider
Staff
spacedivider
Q&A
Billing
spacedivider
Insurance
spacedivider
Payment
spacedivider
Staff Photo

We are not accepting new patients at this time.

We do not provide emergency services or crisis intervention - therefore if the patient is actively suicidal they should seek emergency services or call 911.

Step 1

Please contact our office manager at (360) 545-3416.

Step 2

After contacting our office, we may ask you to complete the patient questionnaire. (Please note: you do not need to fill in the patient questionnaire and other forms until you are instructed.)

Step 3

Please print and complete the patient questionnaire and return it to our office by fax [ 206-202-1985 ] or mail to [ P.O.Box 12257, Olympia WA 98508 ] .

Our office will review the patient questionnaire to be sure that we are an appropriate resource. Our office will contact you for further instructions after we review the questionnaire.

  • Patient Questionnaire (your past and present history) [ Download ]
Step 4

When we are the appropriate resource, the remainder of the forms can then be completed and the patient will be scheduled.

  • Cancellation Policy [ Download ]
  • Practice Policy [ Download ]
  • Authorization to Exchange Healthcare Information - This form will allow us to communicate with your primary care physician or counselor. Be sure to check the type of information you want exchanged. [ Download ]
  • Consultation Referral Request Form - Please be sure that you have the appropriate written referral from your primary care provider. Please fax the referral to us at 360-545-3416 prior to scheduling your first appointment. [ Download ]
  • Patient Consent Form [ Download ]
  • Demographic Information [ Download ]
  • A copy of your insurance card (front and back)

*You can make your time with Dr. States and his associates more valuable by completing critical information before you come to your appointment.

Step 5


Please also read the following policies:

Please bring copies [not originals] of recent labs, x-ray reports, school testing or any other information you think is relevant to your concerns.

You should arrive 20 minutes before your scheduled appointment.

Your appointment(s) will be canceled if we do not receive all paper work 72 hours before your appointment.

*All forms require Adobe Acrobat Reader that you can download by clicking on this link.


Copyright 2010 Adolescent and Young Adult Medicine, P.S. All rights reserved.