Service Request (for Parents/Guardians)

Service Request (for Parents/Guardians)
Your Name*

First NameLast Name
Relationship to patient*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client (Child's) Name*

First NameLast Name
Sex Assigned at Birth (for insurance purposes)*

MaleFemale
Client's Date of Birth*

MonthDayYear
Date
My child's provider has already submitted a referral on their behalf, and I would like to check the status of that referral.*

YesNo
Is the client currently working with a mental health provider (such as a therapist, psychiatrist, counselor, etc.)?*

YesNo
If yes, what is the provider's name and phone number?
How would you like us to contact you?
Preferred Language for Intake Forms*

EnglishSpanish
What language(s) does the child speak and understand?*

EnglishSpanishOther
If the child speaks more than one language, which is the child's preferred language?
What language(s) do the parent/caregiver's speak?*

EnglishSpanishOther
If the parent/caregiver speaks more than one language, which is their preferred language?
For children/adolescents 3 years and older, can they speak in full sentences (three word sentences or more)?*

YesNoOther (e.g., selective mutism)
What service location do you prefer?

Portland Metro: 847 NE 19th Ave, Suite 150, Portland, ORBeaverton: 4900 SW Griffith Drive, Suite 157, Beaverton, ORCentral Oregon: 400 SW Bluff Dr, Bend, OR
Would you like to use insurance for this evaluation? (Please refer to our "Rates & Insurance" page for more information.)*

YesNoUnsure
What type of insurance does the client have?*

Commercial/Private InsuranceOregon Health Plan
Name of insurance company:*
Client/Child's Insurance Member ID #
Which Coordinated Care Organization (CCO) is the client's plan through?

OHP: PacificSource Community SolutionsOHP: TrilliumOHP: Open CardOHP: HealthShare CareOregonOHP: Other CCOI don't know the CCO
OHP ID Number, if known
What kind of testing are you looking for? Please check all that apply:*

Mental health concernsLearning differencesAttention-deficit/hyperactivity disorderAutism spectrum disorderEarly entry to kindergartenGiftednessIndependent Educational EvaluationOther (please specify below)
Anything else you would like us to know?
Should be Empty: