Intake and Referral Forms
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All new clients are asked to arrive 45 minutes before their scheduled appointment unless all forms listed below are completed. Please print and complete all listed forms. If you are unable to do so, please arrive 45 minutes before your scheduled appointment to complete necessary paperwork.
Forms Are Provided in the Free Adobe PDF Format.
Please Make Sure to Download All Applicable Forms in This Category
| A0001 | Adult Information Form | Complete / Return | 5 pages |
| A0002 | Form-Insurance ROI - Oregon Only | Complete / Sign | 1 pages |
| A0002W | Form-Insurance ROI - Washington Only | Complete / Sign | 1 pages |
| A0003 | Policy Statement: General | Read / Sign | 2 pages |
| A0004 | Informed Consent for Treatment or Evaluation | Read / Sign | 3 pages |
| A0005 | Notice of Privacy Practices | Review | 5 pages |
| A0006 | Notice and Acknowledgement: HIPAA | Read / Sign | 1 pages |
Please Make Sure to Download All Applicable Forms in This Category
| C0001 | Child / Adolescent Information Form | Complete / Return | 6 pages |
| C0002 | Form-Insurance ROI - Oregon Only | Complete / Sign | 1 pages |
| C0002W | Form-Insurance ROI - Washington Only | Complete / Sign | 1 pages |
| C0003 | Policy Statement: General | Read / Sign | 2 pages |
| C0004 | Informed Consent for Treatment or Evaluation | Read / Sign | 3 pages |
| C0005 | Notice of Privacy Practices | Review | 5 pages |
| C0006 | Notice and Acknowledgement: HIPAA | Read / Sign | 1 pages |
| C0007 | Minor to Consent to Treatment | Read / Sign | 1 pages |
Please Make Sure to Download All Applicable Forms in This Category
Please Make Sure to Download All Applicable Forms in This Category
| CDC0001 | Child / Adolescent Information Form | Complete / Return | 6 pages |
| CDC0002 | Questions for Parents | Read / Sign | 3 pages |
| CDC0003 | Client Health Self Screen | Complete / Sign | 2 pages |
| CDC0004 | Confidentiality Form: Alcohol and Drug Abuse Patient Records | Read / Sign | 1 pages |
| CDC0005 | Confidentiality Statement | Read / Sign | 1 pages |
| CDC0006 | Policy Statement: General | Read / Sign | 2 pages |
| CDC0007 | Informed Consent for Treatment or Evaluation | Read / Sign | 3 pages |
| CDC0008 | Form-Insurance ROI - Oregon Only | Complete / Sign | 1 pages |
| CDC0008W | Form-Insurance ROI - Washington Only | Complete / Sign | 1 pages |
| CDC0009 | Notice and Acknowledgement: HIPAA | Read / Sign | 1 pages |
| CDC0010 | Notice of Privacy Practices | Review | 5 pages |
| CDC0012 | Statement of Patient Rights | Client Copy | 1 pages |
| CDC0013 | Unprofessional Conduct | Client Copy | 1 pages |
| CDC0014 | Health Insurance Disclosure | Client Copy | 1 pages |
| CDC0015 | HIV / AIDS Self Assessment | Complete / Return | 2 pages |
| CDC0016 | Professional Disclosure: CD Program | Client Copy | 1 pages |
| WS0001 | Informed Consent For Cash Payment | Read / Sign | 1 pages |
| WS0002 | Change / Update of Information | Complete / Return | 1 pages |
| WS0003OR | Authorization to Use and Disclose PHI Clients Receiving Services in Oregon (#10R) | Read / Sign | 1 pages |
| WS0004 | Minor to Consent to Treatment | Read / Sign | 1 pages |
| WS0005 | Policy Statement: Medication Management | Read / Sign | 3 pages |
| WS0006 | Client Complaint Form | Complete / Return | 1 pages |
| WS0007 | Access to Records Form (HIPAA) | Complete / Return | 2 pages |
| WS003WA | Authorization to Use and Disclose PHI Clients Receiving Services in Washington (#1WA) | Read / Sign | 1 pages |
| OHP0001 | OHP Policy Statement | Read / Sign | 2 pages |
| OHP0002 | OHP Letter | Read / Sign | 1 pages |
| OHP0003 | OHP Member Rights / Responsibilities | Read / Sign | 1 pages |
| OHP0004 | OHP Declaration of Mental Health Treatment Acknowledgement Form | Read / Sign | 1 pages |