Skip to content
Menu-new
how can
we help?
Phone
541-423-2633
541-299-5685 (fax)
Email
info@selahcounselingandwellness.com
Eugene/Springfield
175 West B St, Building H
Springfield, OR 97477
Junction City
451 Maple St
Junction City, Or 97448
General Inquiries
New Client Questionnaire
Drop Us A Line
Name
(Required)
First
Last
Email
(Required)
Enter Email
Confirm Email
How Can We Help
(Required)
Please let us know what's on your mind. Have a question for us? Ask away.
New Client Questionnaire
Name
(Required)
First
Last
Is the Client a Minor?
(Required)
Yes
No
Minor Information
Parent/Guardian Name
(Required)
First
Last
Relation to Client
(Required)
Does the Parent/Guardian have full custody of the client?
(Required)
Yes
No
If no, is there a custody agreement?
(Required)
Yes
No
Is there any DHS involvement with the Client?
(Required)
Yes
No
Client Information
Date of Birth
(Required)
MM slash DD slash YYYY
Location Preference
(Required)
Eugene/Springfield
Junction City
Phone
(Required)
Email
(Required)
Primary Insurance
(Required)
Secondary Insurance
Clinician Preference
Schedule preference or limitations
Do you have any previous diagnoses?
(Required)
What are you hoping to work on in therapy?
(Required)
Have you (or the Client) made a suicidal threat or attempt in the last 2 years, or do you (they) have plans to harm yourself (themselves)?
(Required)
Yes
No
Please provide additional details about any suicidal threats during the last 2 years
(Required)
Home
New Client Questionnaire
Services
Acupuncture
Bryce Family Medicine
Individual Therapy
Kids and Teens Therapy
Couples Therapy
Team
ALEX HAGER, LMFT
BRENNON ROTH, LPC
EMMA BOYER, LPC
JACKIE MARTIN, CSWA
JAMIE PLEICH, LPC
JORDAN WILLIAMS, MA
JENNIFER OWEN, MSW, CSWA
JULIE WILLARDSON, NP
LEAH CHANCE, LPC
MIKE MARTIN, LMFT
SARAH LENHART, LPC
SARAH MAY, L.AC.
TIRSA SPARR, LPC
About
Cancellation Policy
FAQs
Rates & Insurance
Locations
Eugene & Springfield
Junction City
Client Portal
Resources
Physical Health Links
Mental Health Links
Recommended Reading
Employment
Licensed Counselors & Therapists
Associates
Contact
New Client Questionnaire
Facebook
Phone
Envelope
