HIPAA Compliant Client Inquiry
Easily, Securely, and Quickly enroll to see a counselor by completing all sections of this form. Once the form has been submitted we will add you to our system, if applicable run a benefits check, and reach out with any questions or concerns we may have. If preferred please call or text the office at 541 343 1728 to book or ask any additional questions you may have. 

We look forward to working with you!
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Who's Submitting This Booking Request?
 *
Required
If Submitting For Someone Else, Please list Your Name
Phone number
Email
First & Last Name (Client)
 *
Date of Birth of Client *
MM
/
DD
/
YYYY
Address for Billing
Primary Insurance
Primary Insurance ID
Secondary Insurance
Secondary Insurance ID
If you are a dependent (Spouse/Partner/Child), list first and last name and date of birth of the primary insurance subscriber for Primary & Secondary Insurance*
What is the best method to contact you?
What are the best day/s to contact you?
What are the best time windows to contact you?
Aside from any checked topics above, is there anything else you would like your counselor to help you with in your work together?
Are there specific counselors you would be open to working with? 
IF 13 YEARS OLD OR YOUNGER:  If Separated/Divorced, Please List The Parent/Guardian Who Has Legal Custody
IF 13 YEARS OLD OR YOUNGER: Who is the client living with?
IF 13 YEARS OLD OR YOUNGER: Who will be navigating appointments, billing needs, & questions?
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