Forms

Patient and Referral Forms are available in PDF format and can be printed with free Acrobat Reader.

Complete and fax (do not email) forms to (608) 835-5010, or mail to: Oregon Mental Health Services, LLC, 165 W. Netherwood St., Oregon, WI  53575. Or forms can be brought with you to your first appointment. All forms will be provided at your first appointment if you choose not to complete them before arriving.

Patient Information and Forms:

Outpatient Client Information Form 

Release of Information  (outpatient and in-home)

Client Rights and Informed Consent  (outpatient and in-home)

FEE Agreement  (outpatient and in-home)

HIPAA Notice of Privacy Practices

Payment Policy (form goes with Fee agreement)

Referrral Information and Forms–In-home:

Please view “Eligibility for In-Home Treatment

In-home Child Information Form PDF

In-home Prescription PDF

Health Check for In-Home Therapy PDF