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Mental Health Form 

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Our therapists are accepting patients on a limited basis. Please call (503) 586-0383 before you fill out the form if you would like to establish care with one of our providers.

Patient Name
Date of Birthyour full name
Phone Numberyour full name
Best time to contactyour full name
What is your current insurance?
Policy Holder's Nameyour full name
Policy Holder's DOB:your full name
Member ID #your full name
Group #your full name
Insurance ID numberyour full name
Are you expecting any changes in your insurance in the next six months?more details
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Name of your current employer?your full name
Do you need to be seen immediately?more details
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Please list any previous mental health diagnosis:more details
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Please list all current medications including any you are taking for mental health:more details
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How did you hear about our clinic?
Please list the best contact number for you:your full name
Can we leave a voice message on the above phone number?your full name
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