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Kolpia Counseling

Integrative Recovery Services in Ashland Oregon

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Forms

New Clients

  • Oriention Packet
    All new and returning clients
  • Telehealth via Video Conferencing Agreement

Returning Clients

  • Oriention Packet
    All new and returning clients
  • Telehealth via Video Conferencing Agreement

Release of Information

  • Release of Information

    Release of Information to provide information to, receive information from, or collaborate with family members or other providers (such as physician, probation officer, MAT prescriber, etc). A separate ROI must be completed for each person/entity you wish for Kolpia to communicate with. Please read instructions carefully, every line requires INITIALS (check marks or Xs will render the ROI invalid).

  • ROI Insurance

    Clients attending services with main focus on substance use treatment (including DUII). If using insurance as payment source, this is required for us to bill your insurance.

Substance Use Treatment

  • Brochure - Digital
  • Brochure - Folded
  • Release of Information

    Release of Information to provide information to, receive information from, or collaborate with family members or other providers (such as physician, probation officer, MAT prescriber, etc). A separate ROI must be completed for each person/entity you wish for Kolpia to communicate with. Please read instructions carefully, every line requires INITIALS (check marks or Xs will render the ROI invalid).

  • ROI Insurance

    Clients attending services with main focus on substance use treatment (including DUII). If using insurance as payment source, this is required for us to bill your insurance.

Legal Mandate After Receiving a DUII

  • DUII Agreement

    Clients completing a legal mandate after receiving a DUII

  • No ADES Agreement

    Clients completing a legal mandate after receiving a DUII, and starting treatment prior to completing their evaluation with the ADSS at community justice

  • Release of Information

    Release of Information to provide information to, receive information from, or collaborate with family members or other providers (such as physician, probation officer, MAT prescriber, etc). A separate ROI must be completed for each person/entity you wish for Kolpia to communicate with. Please read instructions carefully, every line requires INITIALS (check marks or Xs will render the ROI invalid).

  • ROI Insurance

    Clients attending services with main focus on substance use treatment (including DUII). If using insurance as payment source, this is required for us to bill your insurance.

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