New Client Request Form

Thank you for your interest in services with Umpqua Family Therapy. Please complete the information below so our team can determine availability and help match you with the appropriate provider. Please Note: Submitting this form does not establish a therapist-client relationship or guarantee an appointment. Our office will contact you regarding availability and the next steps. This form is not to be used for an emergency. For any emergency or mental health related crisis please call 911 or call/text 988
Who are you seeking services for?
What type of services are you interested in?
Are you looking for
If your preferred therapist is unavailable are you interested in seeing someone else?
Therapist gender preference
Check all days that generaly work for you
Check times that generally work for you
How do you plan to pay for services?
Were you referred to Umpqua Family Therapy by someone?
How did you hear about us?

Before You Submit:

  • I understand that submitting this request does not guarantee an appointment or establish a therapist-client relationship.
  • I understand that this form is not monitored for emergencies or crisis situations.
  • I understand that Umpqua Family Therapy will contact me regarding availability and next steps.
Umpqua Family Therapy LLC
Call or email us! (541) 900-1839 ph (541) 900-1840 fx office@umpquafamilytherapyllc.com
Location:
1000 SE Stephens Street, Roseburg OR 97470
Office Hours Monday- Thursday (Friday depending on providers schedule) 9:00 am - 5:00 pm Therapists hours can vary based on client needs; contact to schedule