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Enrollment Form

1258 High Street, Eugene, OR 97401

Phone 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

If Mental health therapy is selected, are you interested in the Perinatal Program? YesNo

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 (CFD)? GoogleSocial MediaAnother Mental Health Provider (list below)Another Substance Use Recovery Provider (list below)Medical Provider (list below)Family/FriendPsychology TodayInsurance CompanyI'm a Former ClientOther (list below)

Thank you. We look forward to working with you.

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April 17, 2020 1:51 pm PDT

Enrollment Form Uploaded by Do Not Reply - donotreply@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

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April 30, 2020 2:16 pm PDT

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October 28, 2020 10:51 am PDT

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October 28, 2020 1:26 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

October 28, 2020 1:33 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

October 28, 2020 1:39 pm PDT

CFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202

March 18, 2021 2:03 pm PDT

Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:03:02 - 65.157.96.202

March 18, 2021 2:03 pm PDT

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May 3, 2021 10:35 am PDT

CFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202