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Welcome to Selah Counseling & Wellness LLC, we look forward to working together. Let’s be honest, we’re into setting expectations here and the beginning of the therapeutic relationship includes A LOT of paperwork. While we acknowledge this initial process can be overwhelming, we encourage you to pace yourself and to reach out and call with questions or concerns. We sincerely believe everything in the next steps are necessary to evaluate an appropriate level of care and is in your best interest to review carefully. The more detail you provide, the more it equips us as we attempt help you in your therapeutic needs.
Please note that progress cannot be saved for later, so this entire form must be completed to be submitted.

Symptoms & Trauma

We try out best to find the best possible fit for all new clients. Providing the most thorough as and complete symptom and trauma information is essential to this process. Due to state regulations and ethical codes diagnosis is required for treatment. To properly diagnosis the client must be experiencing mental health symptoms.
Symptoms(Required)
Check all that have been experienced in the last 90-days.
Trauma
Select any that have been experienced.

Previous Diagnoses & Therapy Goals

Do you currently have a therapist?(Required)
Provide approximate date of any diagnosis. If there are non please enter "none".
Is the Client a Minor?(Required)
Is the client ready and willing to engage in therapy?(Required)

Minor Information

Parent/Guardian Name(Required)
Does the Parent/Guardian have full custody of the client?(Required)
If there is shared custody or parents are separated and only one has custody, custody paperwork will be required to receive services.
If no, is there a custody agreement?(Required)
Is there any DHS involvement with the Client?(Required)

Client Information

Name(Required)
MM slash DD slash YYYY
This is required by insurance
Communication Preference(Required)

Insurance Information

Will you be using insurance?(Required)
Note: Medicaid/OHP coverage is always last.
Include any "-" or other symbols
Primary subscriber
MM slash DD slash YYYY
Selah is not contracted with this insurance. Depending on the clinician, Out-of-Network benefits may be able to be used depending on your specific plan.
To determine if Selah is contracted with your insurance, we will need to view a copy of your insurance card.
Max. file size: 80 MB.
If possible, please upload images of both the front and back of your insurance card.
I have secondary insurance
Note: Medicaid/OHP coverage is always last.
Include any "-" or other symbols
Secondary subscriber
MM slash DD slash YYYY
Selah is not contracted with this insurance. Depending on the clinician, Out-of-Network benefits may be able to be used depending on your specific plan.
To determine if Selah is contracted with your insurance, we will need to view a copy of your insurance card.
Max. file size: 80 MB.
If possible, please upload images of both the front and back of your insurance card.
Indicate if there is a specific clinician or requirement (gender, treatment, etc.) you are looking for. Preferences are not guaranteed and matching depends on factors such as schedule availability and insurance contracts.
We do not guarantee schedule times but we will take it into consideration when assessing a fit. Selah does NOT have weekend hours and limited evening hours.
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)
Please be a thorough as possible as this information is highly critical.

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Staff

  • ALEX HARRISON
  • ALEX HAGER
  • AMY GESKE
  • BRENNON ROTH
  • EMMA BOYER
  • ERIC GIVEN
  • ERIKA PHILLIPO
  • JACKIE MARTIN
  • JAMIE PLEICH
  • LEAH CHANCE
  • LEVI DOYLE-BARKER
  • KARINA LOPEZ
  • LORNA CASTELTON-CARMAN
  • MIKE MARTIN
  • SARAH LENHART
  • SARAH MAY
  • SCOTT WATERS
  • SETH MURPHY
  • WENDIE MOYNIHAN

About

  • Contact
  • New Client Registration
  • Cancellation Policy
  • FAQs
  • Rates & Insurance

Resources

  • Mental Health Links
  • Physical Health Links
  • Recommended Reading

Employment

  • Associates
  • Licensed Counselors & Therapists

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  • Home
  • New Client Registration
  • Services
    • Acupuncture
    • Individual Therapy
    • Kids and Teens Therapy
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  • Team
    • ALEX HARRISON, MA
    • ALEX HAGER, LMFT
    • AMY GESKE, MS
    • BRENNON ROTH, LPC
    • EMMA BOYER, LPC
    • ERIC GIVEN, MA
    • ERIKA PHILLIPO, MA
    • JACKIE MARTIN, LCSW
    • JAMIE PLEICH, LPC
    • KARINA LOPEZ, MA
    • LEAH CHANCE, LPC
    • Levi Doyle-Barker, MA
    • LORNA CASTELTON-CARMAN, CSWA
    • MIKE MARTIN, LMFT
    • SARAH LENHART, LPC
    • SARAH MAY, L.AC.
    • SCOTT WATERS, LPC
    • SETH MURPHY, MA
    • WENDIE MOYNIHAN, MA
  • 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
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