Forms

ALL FORMS must be completed PRIOR to your intake.

Completed forms can be 

faxed to 855-541-6860 or mailed to 910 Capitol St NE, Building C, Salem, OR 97301.

  • Intake forms are to be completed based on your age.  

  • All other forms need to be completed by all individuals.

  • The paperwork explains your rights, responsibilities, and clinic policies which are important for beginning and continuing care. 

  • Please, complete releases of information for your primary care provider, therapist, and parents (if you are a minor).

Intake-Adult (Individuals 18 years or older)

Intake-Adolescent (Individuals 14 to 18 years of age)

Insurance Form (to be completed by all)

Credit Card Form (to be completed by all)

Release of Information (to be completed by all)

                                     (each PCP, provider, therapist, individual, or place to

                                     authorize and disclose to requires a separate release)

Communication Form

***If you are having an immediate life-or-death emergency, call 911***

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