1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Enrollment Form

Full name (as listed on insurance card, if applicable):

First and last name of person completing this form (if different from person being enrolled):  

Relationship to individual (if different from person being enrolled):  

Preferred name (if different):   Date of birth:

Gender (as identified with insurance company): MaleFemale

Self-identified gender (if different from above): MaleFemaleNon BinaryOther

Gender if Other:  

Pronouns (such as she/her, he/him, they/them, ze/zir, etc.):

Phone number:  

Email address:

I am interested in:  Mental health therapy Substance use treatment Medication Assisted Treatment (MAT)

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

                                                  Can you briefly describe what you hope to get from therapy?

Insurance Provider: OHP (as primary or secondary)MedicareSelf pay (Recovery)Sliding scale (Mental Health)CommercialNone:

Primary insurance ID number (if applicable):

Primary insurance Group number (if applicable):

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

Do you have secondary insurance? YesNo

Secondary insurance ID number (if applicable):  

Secondary insurance Group number (if applicable):  

Thank you. We look forward to working with you.