Becoming a New Client

Please fill out the form below to get started. We will contact you promptly after the form is submitted.

Please be aware that Trillium does not currently contract with Champion Family Therapy and does not allow non-contracted providers to serve their members. If you have Trillium coverage, we are happy to provide referrals to help you get connected with a contracted provider. Call our office at 541-343-7200 or contact Trillium directly for referrals. Effective January 1, 2020, Champion Family Therapy will be contracted with the new Medicaid plan offered by Pacific Source.
CLIENT INFORMATION
Client Name (as listed on insurance card) *
Client Name (as listed on insurance card)
Date of Birth *
Date of Birth
Phone *
Phone
You may provide general information about what you hope to address here or by phone. This will help us to match you with the right therapist to meet your needs.
PRIMARY INSURED SUBSCRIBER INFORMATION
Primary Insured Name *
Primary Insured Name
Date of Birth *
Date of Birth
Phone *
Phone
Address *
Address
Provider Services Phone Number *
Provider Services Phone Number
(usually located on the back of the card)