Intake Forms

Welcome to the intake process for Jackie Hudson Counseling.

If you have spoken with Jackie Hudson by phone and set up your first appointment, please download and complete the following forms. There are four forms that you need to download and fill out or read. Bring the completed forms to your first session. This saves a considerable amount of time. If you would prefer to fill these forms out during your first session with the counselor, the counselor will have forms available on site. The forms are:

  • Intake Form – This form is a page and a half and includes all the information the counselor needs to start, including insurance information. If there is not enough space for your answers please feel free to use the back of the form.
  • Oregon HIPPA Document – This is a two-page form giving you all the information you need to know about privacy. This form is for you to read and keep.
  • Privacy Policy (Acknowledgment and Consent) Signature Form (HIPPA) – This form needs to be signed and given to the counselor. It acknowledges that you have read and given consent to the information contained in the Oregon Notice (HIPPA) form above.
  • Professional Disclosure Statement – The counselor is required by law to have you read and sign this form. This form includes information about the counselor and her approach to counseling, as well as information concerning client’s rights.

* Note that these files all require Adobe’s free Acrobat Reader. To download Adobe Acrobat Reader for free, click here.


You will need to check with your insurance company about coverage. Ask these two questions:

1) Does my policy cover outpatient mental health services? and

2) Does my policy cover my counselor’s license? Not all insurance companies cover all licenses. Your counselor is an LPC (Licensed Professional Counselor).

If you have trouble getting this information you may call Teresa Ewoniuk (Jackie Hudson’s bookkeeper) at 541-912-4478. She may be able to help you determine if you have the coverage needed.