Patient Forms
Primary Care Forms
If you need assistance or would like us to mail you the forms, please call our office at (541) 492-4550.
Adult Forms
Download Adult Primary Care & All Required Forms (English | Español)
- Adult Health History Form
English | Español - Prescription Refill Request
English | Español - Controlled Substance Prescribing Practices
English | Español
Pediatric Forms
Download Pediatric Primary Care & All Required Forms (English | Español)
- Pediatric Health History Form
English | Español - Prescription Refill Request
English | Español - Controlled Substance Prescribing Practices
English | Español
Adult Psychiatric Medical Forms
Download Adult Psychiatric Medical & All Required Forms (English | Español)
- Adult Health History Form
English | Español - Prescription Refill Request
English | Español - Controlled Substance Prescribing Practices
English | Español
Pediatric Psychiatric Medical Forms
Download Pediatric Psychiatric Medical & All Required Forms (English)
- Pediatric Health History Form
English | Español - Prescription Refill Request
English | Español - Controlled Substance Prescribing Practices
English | Español
Mental Health Forms
If you need assistance or would like us to mail you the forms, please call the office nearest you: Douglas County (541) 440-3532, Coos County (541) 751-0357, Curry County (877) 408-8941
Douglas County
Download Adult Mental Health & All Required Forms (English | Español)
Download Pediatric Mental Health & All Required Forms (English)
Coos County
Download Adult Mental Health & All Required Forms (English | Español)
Download Pediatric Mental Health & All Required Forms (English)
Curry County
Download Adult Mental Health & All Required Forms (English | Español)
Download Pediatric Mental Health & All Required Forms (English)
Assertive Community Treatment
Assertive Community Treatment (ACT) Universal Referral Form
Email completed form to: jasminec@adaptoregon.org, suzanneb@adaptoregon.org, and jaimiep@adaptoregon.org
Substance Use Treatment Forms
If you need assistance or would like us to mail you the forms, please call the office nearest you: Douglas County (541) 492-0152, Coos County (541) 751-0357, Josephine County (541) 474-1033, Curry County (877) 408-8941
Douglas County
Download Substance Use & All Required Forms (English | Español)
Coos County
Download Substance Use & All Required Forms (English | Español)
Josephine County
Download Substance Use & All Required Forms (English | Español)
Curry County
Download Substance Use & All Required Forms (English | Español)
Other Forms & Information
Financial Discount Application
English | Español
Audio Video Recording Consent
English | Español
Notice of Privacy Practices
English | Español
Voter Registration
English | Español
Media Release Form
English
This health center receives U.S. Department of Health and Human Services (HSS) funding and has U.S. Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.