Provider Referral Form

  • Date Format: MM slash DD slash YYYY
  • We will use email to confirm we have received the referral. Treatment is not guaranteed.

  • Our wait list for individuals on Oregon Health Plan is currently FULL. Check back frequently as we work diligently to serve these patients as quickly as possible.
  • Date Format: MM slash DD slash YYYY
    Services outside of an evaluation will be determined on a case by case basis after an evaluation has been completed. Evaluation does not guarantee further services. For Medication Assessments we will need records of the last two years from their most recent mental health and primary care providers.
  • Patients diagnosed with an eating disorder will need a cross referral from found here.