Preparing for your Visit

Preparing for Your Visit

New Patient Forms

The Referral Coordinators assist in the processing of potential new patients for all services to Mid-Columbia Center for Living. The intake packet must be presented to Mid-Columbia’s Center for Living Referral Coordinators.
Please download any of the following forms that are applicable to your referral and contact our Intake Referral Coordinators.

Required Documentation

The intake packet includes state required demographic information, an optional voter registration form, an Income and Benefit statement, Referral and Contact Information and a consent to treatment, confidentiality and information on services.

Intake packet
English DocuSign       Spanish DocuSign
English PDF                 Spanish PDF

Client E-Mail, Text Message and Participate in Telehealth Services Informed Consent
English                        Spanish

Informational Documentation
English                       Spanish

Release of Information (ROI)
English                       Spanish

What to Bring Checklist

  • Insurance Card
  • New Patient Forms
  • A list of all medicines; prescription and over the counter (name, dose, and frequency taken) that you are currently taking.
  • A list of any medications that you have allergies to or have experienced an adverse reaction to in the past.
  • Any documents that might be pertinent to your treatment (previous psychological testing, hospital discharge summaries, recent laboratory results, etc.).

General Appointment Information

How do I access services at MCCFL?

If you are seeking services for mental health (MH) and/or substance use disorders (SUD) you can always reach out to our Referral Coordinators for information and support in getting enrolled.

  • If you speak Spanish, all services will need to be scheduled through our Referral Coordinators for both MH and SUD services.
  • If you are a youth or seeking services for one, all services will need to be scheduled through our Referral Coordinator for both MH and SUD services.
  • If you are making a referral for services, we will continue to keep the referent up to date on all the referrals received in our offices, in a timely manner. To help us be able to communicate with you, please have clients complete a Release of Information and send to us at your earliest convenience.

Referral Coordinators

If you have any questions, please call our referral coordinators for assistance.

Hood River- Ludy Quintanilla 541-386-2620 ext 2137 *Se habla Espanol

The Dalles- Yeimi Andrade 541-296-5452 ext  5012 *Se habla Espanol