Prospective Cash-pay Clients

Please fill out the form below to get started. We will be in contact after your form has been submitted.

This form is for clients seeking cash-pay services who will not be billing their insurance; for a list of insurance companies we are in-network with, click here.

After completing this form, please keep an eye on your email for follow-up information.

CLIENT INFORMATION

Client Name

First Name

Last Name

I am interested in:

What type of services are you primarily hoping for?

Telehealth

In office

No preference

Who is filling out this form?

Client Date of Birth

MM

DD

YYYY

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

COVID-19 vaccination status

We have a duty to ask this of prospective clients in order to comply with current OAR's, as well as to prioritize the safety and wellness of all staff and clients at Champion Family Therapy. We do not discriminate based on vaccination status.

I am fully vaccinated

I am not vaccinated

I choose not to disclose and plan to discuss this further with my provider

Reason for Seeking Services

Please provide general information about what you hope to address here or by phone. This will help us to determine how to best meet your needs. If this form is being filled out by someone other than the client, please also include your name here.

Check this box to opt in to text message alerts

Yes, I agree to receive text messages regarding Champion Family Therapy communication

No, I choose to opt-out of texting at this time

Please be aware, we are unable to offer cash-pay services to any clients with OHP due to legislative limitations.