Mental Health Form

Patient Name

Do you need to be seen immediately? Do you need to be seen immediately? Yes (This form is meant to request routine services. If you require immediate consultation, please call us directly at 503-586-0383 and ask to speak to a treatment provider. If you are in immediate danger, please call 911 or proceed to the ER.) No

Reason (if yes)

DOB (mm/dd/yyyy)

Current Insurance

Member ID#

Any expected changes in your insurance coverage in the next six months? Any expected changes in your insurance coverage in the next six months? Yes No

Details (if yes)

Outpatient Mental Health Medicine Outpatient Mental Health Medicine Amanda Lacombe, LMFT, LPC Sandra Munn, LPC Jerry Langholz, LPC, CADC I

Please list all ongoing medical issues:

Please list all current medications including any you are taking for chronic pain:

How did you hear about our clinic?

Please list the best contact # for you

Please enter your email address