Request an Appointment

541-731-4600

Telephone

Client Information

First name

Last name

Date of Birth

Client is a Minor Child In general this office accepts clients ages 14 and older

Yes No

Your First and Last Name if Different from the Client

Phone number

Email address

Accepted clients will need to provide an email address. This is used to set up access to the secure client portal which is required to receive services. Parents, if you coordinate appts for your child, it is recommended you use your email address here. We can add the minor's email address if they would like separate access after the first appt.

About Your Appointment

Current Medications

Please list any medications you are currently taking, dosages are not required. If none please state NONE.

Additional information

If there's anything else that you would like us to know prior to your appointment, please include it here.

Member ID

Relationship to the Insured

Client (self) Client's spouse Client's parent Other

If you are a dependent and are not the PRIMARY insurance holder you need to complete the following information.

Primary Insured's First and Last Name

If different than client

Primary Insured's Date of Birth

If different than client

If you are uncertain as to any information on your insurance card please call the office at 541-731-4600.

If Yes list Name of Secondary Insurance and Member ID

Please also list the name and date of birth of the insured if different from the client.

Your information will be encrypted.

Request an Appointment

541-731-4600

Client Information

About Your Appointment

541-731-4600

Danielle Norris, DNP, APRN, PMHNP-BC