Outpatient Clinic-Based Services Pre-Intake and Referral Form:

Outpatient Clinic-Based Services Pre-Intake and Referral Form:
Please indicate your relationship to the child and click "next" to complete the appropriate form. Referring providers will be directed to complete our Outpatient Referral Form. Legal Guardians and caregivers will be directed to our Caregiver Pre-Intake Form.

This is not a referral for Community Based Services (Level D): If you are seeking Community-Based Services for a youth, please contact the youth's Behavioral Health Insurance Provider to determine eligibility and referral/authorization requirements. Our community-based services require a referral from a current mental health provider and are only available for select insurance plans.
You are a:

Provider/ Caseworker Referral Form

If you are a provider or DHS caseworker, an would like to complete our online referral form, please press the "next" button to be directed to our online referral form. If you prefer to complete our downloadable referral form, please select the option below. Once a referral form has been submitted, a member of our Central Intake team will reach out to the family to establish services.

Client Name

Client First NameClient Last Name
Client Date of Birth

MonthDayYear
Legal Guardian Name

Legal Guardian First NameLegal Guardian Last Name
Legal Guardian Phone Number
Please enter caregiver's phone number.Format: (000) 000-0000.
Legal Guardian Email Address
Please enter caregiver's email address.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who does the child live with?
If different from Legal Guardian information, please include name and contact information.
Referring Provider Information
Provider's Name:

First NameLast Name
Provider's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Provider's email:
example@example.com
Provider's relationship to the client:
Your name, relationship to the client, and contact information.
Spoken language:
Insurance Information

At Morrison we provide mental health counseling services for children covered by the Oregon Health Plan, Providence, Moda, Pacific Source, or Kaiser insurance. We do not accept out-of-pocket pay.
Insurance Provider
Medical Identification Number:
Identified Concerns/ Observations:
Why are you seeking services for this child?
Morrison Site Requested:
Additional information:

For Parents/Caregivers:

Please click the link below to complete our Caregiver Pre-Intake Form to establish your child with Morrison Child and Family Services. We ask that you are as detailed as possible in your responses. Once we receive your screening form, we will give you a call when we have appointments available to schedule.
Caregiver Pre-Intake Form

Provider/ Caseworker Referral Form