Intake Prescreen Form
Hello!  Thank you for reaching out to us at North Albany Wellness Center.  We are grateful you have chosen to seek counseling services.  In order to begin the intake process we will need the information requested below.

Please only complete this form once!

If you are experiencing a mental health emergency or are currently suicidal please consider the following resources:

- Dial 988 for the National Suicide Hotline
- Linn County Crises Hotline 1-800-304-7468
- Benton County Mental Health Crisis Hotline 888-232-7192 (or text OREGON to 741741)
- Call 911 or go to your nearest emergency room

We are not able to bill OHP Open Card, Medicare, Tricare/VA, PacificSource OHP.
We do not have a psychiatric prescriber.

We are unable to take clients that are currently seeking counseling to obtain support solely for a legal case such as custody related issues, worker’s compensation, getting on social security, or mandated therapy.
Visit our Services page (https://northalbanywellnesscenter.com/counseling-services-and-fees) for more information of what we can and cannot treat.
Sign in to Google to save your progress. Learn more
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of North Albany Wellness Center. Report Abuse