Forms for Counseling Clients

Welcome New Clients!

To begin utilizing our Counseling services, please call 541-757-8068 and speak with our Intake Coordinator. After completing our phone intake, complete and return the appropriate forms below prior to your initial appointment/mental health assessment.

Return forms to Lisa Field, Intake Coordinator & Clinical Specialist via:

New Client – Minor (under age 14 years)

Parent/guardian, read and review: Then complete and submit:
Counseling Services Information Packet Counseling Services Agreement
Privacy Practices Booklet Consent to Treat
Demographic, Contact & Reminder Information
Telemental Health Informed Consent
Financial Agreement
General Release of Information (ROI)
School ROI
Physician ROI
Foster Care ROI (only applies to clients in DHS care)
AND a copy of your photo ID

New Client – Teen or Adult (age 14+)

Please read and review: Then complete and submit:
Counseling Services Information Packet Counseling Services Agreement
Privacy Practices Booklet Consent to Treat
Client Rights Demographic, Contact & Reminder Information
Telemental Health Informed Consent
Financial Agreement
General Release of Information (ROI)
School ROI
Physician ROI
AND a copy of your photo ID

Current Clients – Grievance Process

Old Mill Center continually strives to provide the highest quality of care. If, however, you have a concern regarding your counseling experience, we encourage you to submit the following form at any time. We will respond in writing within 20 calendar days.