Application Screening & Intake Packets

Client Screening Application Packet

  • Client File Signature Packet   client signiture packet
  • Assessments/Questionnaires 
    • Attachment Style
       The Attachment Project: Learn Attachment Theory from Experts
      Attachment Styles Test: Attachment Style Quiz from Dr. Diane Poole Heller
      Life Events Checklists
      ·       LEC-5 (standard self-report) (PDF)
      ·       LEC-5 (extended self-report) (PDF)
      ·       LEC-5 Interview (with abuse ratings) (PDF)
      Brief Trauma Questionnaire
      Brief Trauma Questionnaire (
      Trauma screening (symptoms) Questionnaire
      FLSI13TSQ.pdf (
Intake Process
Step One:
o   Email Client Information Packet
o   Email Client Intake Application
o   Client returns application with non-refundable intake Fee $75
o   Clinician calls for an introduction interview. If both agree to a working relationship
o   Note: If relationship/group or family sessions, all persons must complete their own paperwork and submit it prior to moving to the next step. ***
Step Two
o   Email Client File Packet
o   Client Completes Signature Pages
o   Email Client Questionnaire(s)/ Assessments
o   Client Completes Proposed Questionnaire/Assessments
o   Client Returns signed file packet, questionnaire, and assessments to the clinician.
o   Client pays $125 flat fee non -refundable Assessment Compilation. Each assessment has an additional fee to complete the report 
Step Three
o   Clinician Compiles assessments reviews
o   Clinician calls client for treatment interview 1st or 2nd face-to-face meeting
o   Clinician and client Work on Treatment Plan.

Individual Sessions: Coaching $100 an hour; Trauma Counseling $150 an hour;  Insurance in Oregon Potential. (Pacific Source)  Sliding Scale Fee negotiable. 

Couples Sessions: Prepare & Enrich (10-12 sessions)- $125 an hour. Other expenses include the assessment fee and workbook paid to the Prepare & Enrich Program.

Group fees as described per group

Other fees that may apply include but are not limited to mileage, copies, phone/email communication, additional assessments, assessment reports, resource workbooks.

- Financial Information