Shoreline Counseling, LLC Secure Contact Form:

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julie@scllcor.com

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Shoreline Counseling is an outpatient mental health group practice that generally sees clients for 1 hour a week. Due to this, we are not the appropriate place of service for clients who have had a recent suicide attempt with continued SI, primary substance use disorder diagnosis or anyone who is having active psychosis. Shoreline Counseling also does not currently have any therapists who provide couples counseling. We can work to refer anyone with these areas of focus to a more appropriate practice so you can get the support and level of care that you deserve.

What to expect after you hit submit:

You will be contacted by our Intake Coordinator within 24 business hours. If you prefer to leave us a voicemail, you can do so by dialing 971-350-6474. We can be reached via email at connect@scllcor.com. Faxed referrals can be sent to 888-971-4017.

Name of person seeking services: *

Age of person seeking services: *

Your name and relationship if different than above:

Phone number: *

Primary (and Secondary if applicable) Insurance. (By having this information before we speak to you will allow for us to identify which therapists will be able to take your insurance, what your benefits cover and if the therapist identified will be in or out of network). *

Are you requesting a specific Shoreline Clinician?

Services requested: *

Counseling

Medication Management

Counseling and Medication Management

Psychological testing - ADHD, Autism or differential diagnosis

How did you hear about Shoreline? *

Please share more information about what you are hoping for support with: *

Preferred method of contact *

Phone

Text message - By checking this box - I am consenting to insecure contact via text messages and will click Option 1 below.

Other:

Non Secure Communications Acknowledgement: *

Option 1 - Agree to the use of conventional text. Conventional texting is inherently insecure and therefore poses a risk to the privacy and security of my Protected Health Information. I accept these risks and consent to Shoreline Counseling, LLC's therapist’s and office staff communicating with me via unsecured text with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment. By submitting, you agree to receive text messages at the provided number from Shoreline Counseling, LLC. Message frequency varies, and standard message and data rates may apply. You have the right to OPT-OUT receiving messages at any time. To OPT-OUT, reply "STOP" to any text message you receive from us. Reply HELP for assistance.

Option 2 - Contact will be made only through secure email, portal messaging and phone calls. I only wish to be contacted via secure communication means which does not include texting, until such time as I may elect to make a request for communication via non-secure means.

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