BEHAVIORAL HEALTH INFORMATION
Options Location:Options Counseling and Family Services Location: Beaverton - 8285 SW Nimbus Ave, Ste 148; Beaverton, OR 97008 Fax: (503)352-3262Clackamas - 12901 SE 97th Ave, Ste 340; Clackamas, OR 97015 Fax: (503)655-6806Eugene - 1255 Pearl St, Ste 102; Eugene, OR 97401 Fax: (541)687-2063Florence - 1445 8th St; Florence, OR 97439 Fax: (541)997-8606Multnomah - 11010 SE Division St, Ste 202; Portland, OR 97266 Fax: (503)335-5974Newport - 119 NE 4th St; Newport, OR 97365 Fax: (541)264-7515North Salem - 2645 Portland Road NE, Ste 120; Salem, OR 97301 Fax: (503)393-3135Roseburg - 283 SE Fowler St, Ste 2; Roseburg, OR 97470 Fax: (541)464-6457South Salem - 1515 Liberty St SE; Salem, OR 97302 Fax: (503)468-3130Springfield - 175 West B St, Bldg D; Springfield, OR 97477 Fax: (541)762-1974St. Helens - 445 Port Ave, Ste C; St. Helens, OR 97051 Fax: (503)335-5974Woodburn - 1320 Meridian Dr; Woodburn, OR 97071 Fax: (503)498-5810
What services are you seeking? Therapy Med Management Skills Training What is the main reason you’re seeking services at this time?
Please mark any concerns you or your child have in the following areas. (Select only those that apply to the client). sad, depressed cry easily mood swings can’t sleep sleeping too much tired often muscle tension can’t eat eating too much feel anxious, nervous panic/anxiety attacks often fearful, afraid easily startled feel overwhelmed worry often feel stressed feel worthless easily angered aggression irritability obsessive behaviors self harm behaviors thoughts of suicide nightmares flashbacks can’t remember things can’t concentrate hyperactivity problems learning hearing voices seeing things that are not there alcohol/drug use
The following symptoms affect or may be affected by your (or your child’s) behavioral health needs. Please check if any of the following are currently affecting your life. moving housing concerns homeless job loss death/grief concerns about children child with special needs abuse in family domestic violence alcohol/drugs in family concerns about a parent family conflicts divorce relationship concerns pregnancy physical health concerns legal issues/criminal record
Are you (or your child) currently taking any medications?
Client Name : Relation to Client : SelfParent / GuardianLegal CustodianGuardianOther, as listed
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Document Name: BEHAVIORAL HEALTH INFORMATION
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