Self-Referral Form

Self-Referral Form

If you have questions, please call our main office at (541) 485-6340.
Name*

First NameMiddle InitialLast Name
Is this the name used for your insurance?*
Please write in the full name as it is listed on for insurance
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Is your mailing address the same as your physical address?

YesNo
Your date of birth is required in order to verify insurance.

You may provide this information on this form or by phone.

If you select the option "Please call me," we will reach out to you by phone during our business hours (Monday-Friday, 8am-5pm). Please note: This option may delay the next steps for LHC services if we do not reach on our initial call to you.
How will you provide your date of birth?*

I'll provide on this formPlease call me to provide it by phone
Date of Birth*

MonthDayYear
Date
Legal Gender*

MaleFemale
Select your Insurance Provider*
How can we help?*
Are you new to Laurel Hill Center?*

YesNo
Are you currently receiving services from another behavioral health provider?*

YesNo
What is your preferred language?
CONSENT FOR FOLLOW-UP

To ensure privacy, Laurel Hill Center requires verification of an individual's consent to be contacted prior to outreach.
Consent for LHC's identification through email*

YesNo
Consent for LHC's identification through voicemail*

YesNo
Should be Empty:

CONSENT FOR FOLLOW-UP