Contact Us

Restore Hope, Renew Lives

Intake Form

General Questions:

If your question or concern needs immediate attention, please call our office at 541-942-3939. Otherwise,

For questions about client services, mental health issues,and general information about South Lane Mental Health contact info@slmh.org
For questions about billing, payroll, and insurance, contact businessadmin@slmh.org
For questions about employment and/or job openings, contact employment@slmh.org
For media or donor questions, contact development@slmh.org

This website is not a crisis line.

If you are having a mental health emergency and live in Oregon’s South Lane County, please call 911.

Intake Scheduling Form

Legal Name

Preferred Name

SSN

DOB (MM/DD/YYYY)

Phone

Is it okay to leave a message?

Even if the message is left with a Parent or Gaurdian?

Address

What kind of Insurance coverage do you have?

Subscriber Name:

Member ID/Policy ID#:

Group #:

Do you have Secondary Insurance?

Insurance Carrier:

Subscriber Name:

Member ID/Policy ID#:

Group #:

Have you or a family member received services at SLMH before?

If yes, Previous Counselor/Prescriber?

Is there anyone that you cannot have contact with, due to a restraining or no contact order?

If Yes, Name of Person(s)

By checking this box, I authorize South Lane Mental Health to contact me using the phone number I have provided above.

Yes

Cottage Grove - Main Office

1345 Birch Ave
Cottage Grove, OR 97424
M – W & F 8am – 5pm
Thurs 8am – 6pm
541-942-3939
Fax: 541-942-9310

Bohemia Residential Center (Adult Foster Home)

1115 W Main Street
Cottage Grove, OR 97424
541-942-3939

Downtown Building

37 N 6th St
Cottage Grove, OR 97424
541-942-3939

East Building

1245 Birch Ave
Cottage Grove, OR 97424
541-942-3939

Island Park

288 Mill Street
Springfield, OR 97477
541-942-3939

Recovery Center

75 S 5th St.
Cottage Grove, OR 97424
541-942-3939
Fax: 541-649-1697

Office Locations

(541) 942-3939