Becoming a New Client
Please fill out the form below to get started. We will be in contact after your form has been submitted.
For a list of insurance companies we are in-network with, click here. Prior to becoming a new client, we require copies of your insurance card, front and back; these copies are requested below. If you are looking for the form to become a cash-pay client and do not plan to bill health insurance, please click here.
After completing this form, please keep an eye on your email for follow-up information about beginning our therapy process. If you are eager to begin services, please complete consent forms and an intake packet found on the forms tab at the top of this page. Completing these forms can expedite the scheduling process.
We encourage you to contact your insurance company to verify your coverage and determine what out-of-pocket costs you will be responsible for.
In addition to several private insurers, Champion Family Therapy is contracted with the OHP/Medicaid plan offered by PacificSource, and is happy to serve this population.
Please be aware, Trillium OHP is not contracted with Champion Family Therapy at this time, and does not allow non-contracted providers to serve their members. If you have any questions about this, please call our office at 541-343-7200.