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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.
Aggression/fights
Anxiety/Worry
Auditory hallucinations
Bed wetting
Boredom
Change in appetite
Co-Parenting conflict/dynamics
Crying spells
Decreased need for sleep
Delusions
Developmental delays
Did not meet developmental milestones
Difficulties adjusting in family dynamics
Difficulties in parent child dynamics
Difficulty in a classroom setting
Dissociation
Distractibility/Inattention
Excessive alcohol use
Excessive cannabis use/Addiction
Excessive energy
Fatigue
Fear leaving home
Feeling restless
Flashbacks
Flight of ideas
Gambling problems
Gender concerns
Guilt/shame
Hearing voices
Homicidal thoughts
Hopelessness
Hypervigilance
Impulsivity
Increased irritability
Inflated self-esteem
Interrupts others
Intrusive/Disturbing Memories
Irritability/Anger
Lack of motivation
Learning disabilities
Loss of interests
Low self-worth
Memory Loss
Moving/Speaking so slowly other have noticed
Nicotine addiction
Nightmares
Night-time worries/fears
Obsessive thoughts/behaviors
Often does not follow through on tasks
Often fidgets/Difficulty sitting still
Often forgetful in daily tasks
Often talks excessively
Panic attacks
Peer conflict
Phobias
Poor appetite/Overeating
Pressured speech
Problems with pornography
Racing thoughts
Repeated and intrusive thoughts
Risk taking behaviors
Sadness/depression
Seasonal mood changes
Self-harm behaviors
Sexual problems
Skin picking/hair pulling
Sleep problems
Social Discomfort
Substance abuse
Suicidal ideation
Suspicion/Paranoia
Tech addiction
Triggers Feeling
Trouble concentrating
Visual hallucinations
Trauma
Select any that have been experienced.
Bullying
Chronic illness
Community violence
Domestic Violence (current)
Domestic Violence (historic)
Emotional abuse
Financial problems
Homelessness
Life threatening illness
Lived in foster home
Loss of a loved one
Military combat incident
Multiple family home
Natural disaster
Neglect
Parent chronic/ terminal health condition
Parent incarceration
Parent substance abuse
Physical abuse
Placed a child for adoption
Racial trauma
Sexual abuse
Sexual assault
Teen pregnancy
Terrorism
Traumatic childbirth
Witness death by suicide
Other
Please explain "other" trauma
(Required)
Previous Diagnoses & Therapy Goals
Have you ever been involved with the criminal justice system?
(Required)
No
Yes
Accused or convicted of any misdemeanors or felonies.
Are you looking for/needing court mandated therapy?
(Required)
No
Yes
NOTE: Selah does not provide court mandated therapy.
Provide a complete explanation of any charges and/or convictions including the year and sentence.
(Required)
What type of therapy are you looking for?
(Required)
Individual Therapy
Family Therapy (couples)
Family Therapy (parent/child)
Do you currently have a therapist?
(Required)
No
Yes
Please provide detail on who you are seeing and what for.
(Required)
Do you have any previous diagnoses from a previous clinician or medical provider?
(Required)
Provide approximate date of any diagnosis. If there are non please enter "none".
What are you hoping to work on in therapy?
(Required)
Is the Client a Minor?
(Required)
Yes
No
Is the client ready and willing to engage in therapy?
(Required)
Yes
No
Minor Information
Parent/Guardian Name
(Required)
First
Last
Relation to Client
(Required)
Relation to client
Mother
Father
Guardian
Step-Parent
Relation detail
(Required)
Does the Parent/Guardian have full custody of the client?
(Required)
Yes
No
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)
Yes
No
Is there any DHS involvement with the Client?
(Required)
Yes
No
Client Information
Name
(Required)
First
Middle
Last
Preferred Name
Date of Birth
(Required)
MM slash DD slash YYYY
Age
Gender at Birth
(Required)
Select
Male
Female
This is required by insurance
Gender Identity
Choose not to disclose
Female
Male
Trans Woman
Trans Man
Non-binary
Sexual Identity
Choose not to disclose
Asexual
Bisexual
Gay/Lesbian
Straight
Pronoun
Race/Ethnicity
Relationship Status
Single
Married
Partnered
Polyamorous
Widowed
Address
(Required)
City
(Required)
State
(Required)
Select
AL
AK
AZ
AR
CA
CZ
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VI
VA
WA
WV
WI
WY
Zip Code
(Required)
Phone
(Required)
Email
(Required)
Communication Preference
(Required)
Phone
Email
Contacts
Please enter an emergency contact and then all people living in the home or anyone who may bring the client to an appointment.
Emergency Contact
(Required)
Name
Phone
Email
Relation to Client
Contacts
Name
Phone
Email
Relation to Client
Add
Remove
Insurance Information
Will you be using insurance?
(Required)
I will be using insurance
I will not be using insurance
Primary Insurance Company
(Required)
Select
Aetna
Benefit Administrative Systems
BridgeSpan
Care Oregon Inc
CAS
ChampVA
Cigna
Coquille Indian Tribe
EBMS
First Choice Health Network
Harrison Trust
Healthcare Management Administrators
Healthcomp Inc
HealthNet
Health Share of Oregon
InterCommunity Health Network
Kaiser PPO
Kaiser HMO
Meritain Health
MODA
OHP Open Card
PacificSource Community Solutions
PacificSource Health Plans
Providence Health Plans
Regence Blue Cross Blue Shield
Regence Group Administrators
Samaritan Health Plans
Trillium Community Health Plan
UMR
UnitedHealthcare
Other
Note: Medicaid/OHP coverage is always last.
Other Insurance Name
(Required)
ID/Member #
(Required)
Include any "-" or other symbols
Group #
Primary subscriber
Client is not the subscriber
Subscriber
(Required)
Subscriber DOB
(Required)
MM slash DD slash YYYY
Relation to Subscriber
(Required)
Select
Spouse
Child
Life Partner
Other
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.
File
Max. file size: 80 MB.
If possible, please upload images of both the front and back of your insurance card.
I have secondary insurance
I have secondary insurance
Secondary Insurance Company
(Required)
Select
Aetna
Benefit Administrative Systems
BridgeSpan
Care Oregon Inc
CAS
ChampVA
Cigna
Coquille Indian Tribe
EBMS
First Choice Health Network
Harrison Trust
Healthcare Management Administrators
Healthcomp Inc
HealthNet
Health Share of Oregon
InterCommunity Health Network
Kaiser PPO
Kaiser HMO
Meritain Health
MODA
OHP Open Card
PacificSource Community Solutions
PacificSource Health Plans
Providence Health Plans
Regence Blue Cross Blue Shield
Regence Group Administrators
Samaritan Health Plans
Trillium Community Health Plan
UMR
UnitedHealthcare
Other
Note: Medicaid/OHP coverage is always last.
Other Insurance Name
(Required)
ID/Member #
(Required)
Include any "-" or other symbols
Group #
Secondary subscriber
Client is not the subscriber
Subscriber
(Required)
Subscriber DOB
(Required)
MM slash DD slash YYYY
Relation to Subscriber
(Required)
Select
Spouse
Child
Life Partner
Other
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.
File
Max. file size: 80 MB.
If possible, please upload images of both the front and back of your insurance card.
Location Preference
(Required)
Eugene/Springfield
Junction City
Telehealth
How did you hear of us?
Clinician Preference
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.
Schedule preference or limitations
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.
Medical History
PCP (Primary Care Physician)
(Required)
Practice/Organization
Name of the practice of your PCP.
Current Medications
Medication
Treating
Started (mm/yy)
Add
Remove
List all prescription medications currently being taken.
Do you have any chronic health conditions, major injuries, surgeries, concussions/head injuries, etc.
(Required)
No
Yes
Please explain, and include any approximate dates or timelines.
(Required)
Add
Remove
Have you ever had a history of or current issues with: chronic dieting, severely restricting food intake or food variety, purging, binging, or compulsive exercising.
(Required)
No
Yes
Please explain, and include any approximate dates or timelines.
(Required)
Do you have any previous mental health diagnoses from a mental health provider?
(Required)
No
Yes
Please list the diagnoses, clinician who diagnosed and approximately when.
(Required)
Diagnosis
Medical Professional
Year Diagnosed
Add
Remove
Have you ever engaged in self-harming behavior? (e.g. cutting, burning, intentional bruising, etc.)
(Required)
No
Yes
Please list and provide approximate date (month and/or year) or timeline.
(Required)
Behavior
When
Add
Remove
Have you ever been hospitalized for mental health reasons?
(Required)
No
Yes
Please list location and dates.
(Required)
Where
When
Add
Remove
Do you have a history of violence or aggression?
(Required)
No
Yes
Please describe including any dates.
(Required)
Has this led to any legal involvement?
(Required)
No
Yes
Do you have a history of abusing drugs or alcohol?
(Required)
No
Yes
Please describe and include any dates/time frames.
(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 attempts during the last 2 years (including dates).
(Required)
Please be a thorough as possible as this information is highly critical.
Family Psychiatric History
History of (diagnosed or suspected)
Depression
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Bipolar Disorder/Manic Depression
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Anxiety
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Schizophrenia/Schizoaffective
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Autism/Developmental Disorder
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Post-Traumatic Stress Disorder (PTSD)
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Obsessive Compulsive Disorder (OCD)
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
ADHD/Hyperactivity
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Substance/Alcohol Abuse
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Learning Disorder
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
History of (diagnosed or suspected)
Anorexia/Bulimia/Eating Disorder
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
Other
Who?
Mom
Dad
Brother
Sister
Grandparent
Aunt
Uncle
Cousin
Functional Assessment
These questions are to help your clinician as they assess how symptoms impact your daily life.
What is your highest level of school completed?
(Required)
Did not complete High School
High School diploma
GED
Some College
Associate's
Bachelor's
Masters
Doctorate
Are symptoms affecting educational/school performance?
(Required)
No
Yes
e.g. difficulty with peers, academics/grades, disciplinary action, etc.
Explain
(Required)
Are symptoms affecting employment/work performance?
(Required)
No
Yes
e.g. difficulties with co-workers, disciplinary actions, attendance, job loss, etc.
Explain
(Required)
Are symptoms affecting social life?
(Required)
No
Yes
e.g. withdrawing from friends, isolation, conflict, etc.
Explain
(Required)
Home
New Client Registration
Services
Acupuncture
Individual Therapy
Kids and Teens Therapy
Couples Therapy
Team
ALEX HARRISON, MA
ALEX HAGER, LMFT
AMY GESKE, MS
BRENNON ROTH, LPC
EMMA BOYER, LPC
SHAY SEIMARS, 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
SHAY SEIMARS, MA
WENDIE MOYNIHAN, MA
About
Cancellation Policy
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Locations
Eugene & Springfield
Junction City
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Physical Health Links
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