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Enrollment Form

Center for Family Development

1258 High Street, Eugene, OR 97401 – 541-342-8437 / Fax 541-242-2999

Enrollment Form

Full name (as listed on insurance card):

Preferred name (if different): Date of birth:

Gender (as identified with insurance company): MaleFemale

Self-identified gender (if different from above): MaleFemaleOther

Pronouns used (such she/her/hers, he/him/his, they/them etc.):

Phone number: Email address:

I am interested in: Mental health therapySubstance use disorders treatment

Do you want to set up services for yourself or someone else? MyselfMy child

What service(s) are you interested in? Individual therapy Family therapy

Insurance Provider: TrilliumPacificSource Community SolutionsMedicareOther:

Insurance ID number:

Insurance Group number:

Provider services phone number (as listed on insurance card):

Do you have secondary insurance? YesNo

How did you hear about Center for Family Development? GoogleFacebookAnother Mental Health ProviderMedical ProviderFamily/FriendPsychology TodayInsurance CompanyI’m a Former ClientOther:

Thank you. We look forward to working with you.

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Timestamp

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April 17, 2020 1:51 pm PDT

Enrollment Form Uploaded by Jason Dooley - jdooley@c-f-d.org IP 65.157.96.202

April 29, 2020 8:26 am PDT

Records Department - records@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 29, 2020 9:23 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 29, 2020 1:58 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 29, 2020 2:02 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 29, 2020 2:03 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129

April 30, 2020 2:16 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225

May 5, 2020 9:34 am PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225