Intake Form

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Welcome to my practice!

Client Registration Packet - Please complete this form before your first appointment. This packet includes everything you will need to get started.

Client Intake Checklist - Fill this out before your first appointment so that we can get started right away. This includes a downloadable form that covers a wide range of symptoms.

Make an Appointment.

Insurance Carriers - Here is a list of companies that will accept me as an outpatient provider for mental health.

Outpatient Mental Health Benefits Summary - A Questionnaire for your Insurance company to see if you are eligible to receive benefits covering your sessions with me. You can download the PDF version and fill it out as you speak with your insurance provider.

Why Private Pay? - even if you have insurance benefits, you may choose to pay for your sessions and not make a claim.

Payments - in order to reserve your first appointment, you must pre-pay to hold your spot. You can use your credit card or PayPal to reserve your time.

Personal History Form (Children and Adolescents)

Personal History Form (18+)

Office Hours:
Monday - Friday, 8 a.m. - 8 p.m.
Saturday Mornings

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New Client Interview

ONLY required once. New Clients are encouraged to Pre-Pay for their first interview session to protect their time slot.

Download files needed Registration Packet  

Appointments scheduled for you are set aside expressly for you, therefore any not kept will be billed unless canceled 48 hours in advance.

Dr. Ray Smith


Ray Wm. Smith, Ed.D
9507 N Division Street Suite A
Spokane, WA 99218-1556

Phone: (509) 466-6632
Fax: (509) 466-0117
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Office Hours:
Monday - Friday, 8 a.m. - 8 p.m.
Saturday Mornings