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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
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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.