Provider Referral Form

  • Date Format: MM slash DD slash YYYY
    We are currently open to pediatric patients with OHP only. Our waitlist is closed for all other patients at this time.
  • We will use email to confirm we have received the referral. Treatment is not guaranteed.

  • Our waitlist is currently closed to all patients except pediatric patients with Oregon Health Plan.
  • 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.
  • Patients diagnosed with an eating disorder will need a cross referral from found here.