[] 1 Step 1 Patient Nameyour full name Do you need to be seen immediately?Yes / This form is meant to request routine services. If you require immediate consultation, then 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 Reasonif yes DOBmm/dd/yyyy Current Insurance Member ID#(from insurance card) Any expected changes in your insurance coverage in the next six months?YesNo Detailsif yes0 / Outpatient Mental Health MedicineAmanda Lacombe, LMFT, LPCDeanne Comfort, LPCJerry Langholz, LPC, CADC I Please list all ongoing medical issues?0 / Please list all current medications including any you are taking for chronic pain0 / How did you hear about our clinic? Please list the best contact # for you Please enter your e-mail address Submit Form Previous Next powered by FormCraft
