Parenting through Change Interest Form – Oregon Community Programs

Thank you for your interest in PTC^TM groups! Please take a moment to complete the form below, or you can contact the Program staff directly.

Andrew Stevens
(541) 743-4351
OR
Evyan Stuart
(541) 743-4348

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Child's Name

First

Last

Child's Date of Birth

Please share why you are seeking services or list the behaviors of concern. *

County of Residence: *

Insurance

My child has Oregon Health Plan
My child is uninsured or has commercial insurance and I would like more information about eligibility for PTC group.

OHP ID#

Phone *

Contact Email *

What is your preferred method of contact? *

Best time of day for us to contact you?

How many children under the age of 18 are residing in your home?

Preferred group time? (Check all that apply)

How did you hear about Parenting through Change? *