Intake Screening and Referral Form:
Please indicate your relationship to the child and click "next" to complete the appropriate form.
You are a:
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Parent/Caregiver
Provider
DHS Caseworker
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Provider/ Caseworker Referral Form
If you are a provider or DHS caseworker, an would like to complete our online referral form, please press the "next" button to be directed to our online referral form. If you prefer to complete our downloadable referral form, please select the option below. Once a referral form has been submitted, a member of our Central Intake team will reach out to the family to establish services.
Please select this option if you would like to be directed to our downloadable Referral Form (PDF)
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Client Name
*
Client First Name
Client Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Legal Guardian Name
*
Legal Guardian First Name
Legal Guardian Last Name
Legal Guardian Phone Number
*
Please enter caregiver's phone number.
Legal Guardian Email Address
*
Please enter caregiver's email address.
Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Who does the child live with?
*
If different from Legal Guardian information, please include name and contact information.
Referring Provider Information
Provider's Name:
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First Name
Last Name
Provider's Phone Number:
*
Please enter a valid phone number.
Provider's email:
*
example@example.com
Provider's relationship to the client:
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Your name, relationship to the client, and contact information.
Spoken language:
*
Insurance Information
At Morrison we provide mental health counseling services for children covered by the Oregon Health Plan, Providence, Moda, Pacific Source, or Kaiser insurance. We do not accept out-of-pocket pay.
Insurance Provider
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Oregon Health Plan (Including CareOregon/Health Share/Yamhill CCO/Trillium/Pacific Source)
Kaiser
Moda
Providence Health Plan
Pacific Source (Commercial)
Medical Identification Number:
Identified Concerns/ Observations:
*
Why are you seeking services for this child?
Morrison Site Requested:
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Portland (1507 NE 122nd Ave, Portland, OR 97230)
Gresham (831 NW Council Dr. Suite 300, Gresham, OR 97030)
Beaverton (15455 NW Greenbrier Pkwy Suite 200, Beaverton, OR 97006)
Milwaukie (4105 SE International Way, Suite 504, Milwaukie, OR 97222)
Additional information:
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For Parents/Caregivers:
Please click the link below to complete our Caregiver Screening Form to establish your child with Morrison Child and Family Services. We ask that you are as detailed as possible in your responses. Once we receive your screening form, we will add the child to our waitlist and give you a call when we have appointments available to schedule.
Caregiver Screening Form
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