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Patient Forms

Primary Care

Mental Health

Substance Use Treatment

Other 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)

Pediatric Forms

Download Pediatric Primary Care & All Required Forms (English | Español)

Adult Psychiatric Medical Forms

Download Adult Psychiatric Medical & All Required Forms (English | Español)

Pediatric Psychiatric Medical Forms

Download Pediatric Psychiatric Medical & All Required Forms (English)

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.