Becoming a New Client

Client Name (as listed on insurance card) *

First Name

Last Name

What type of therapy are you primarily hoping for? *

Telehealth

In office

No preference

Client Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

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 therapist

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

Primary Insured Member Name

Required if different from Client

First Name

Last Name

Primary Insured Member Date of Birth

Required if different from Client

MM

DD

YYYY

Does the client have secondary health insurance? *

Yes

No