LifeWorks NW provides quality and culturally responsive prevention, mental health and addiction services in numerous Portland area facilities.
To make it easy to refer clients or find a service for yourself, we have several options for you. Fill out our Request for Service Form or call us at 503-645-9010 or 1-888-645-1666.

Your Information



*First Name:

*Last Name:

*Phone Number:

*Email:

Organization or Agency:

*Inquiring Services For:
Myself
My Child
My Parent
My Spouse or Partner
My Client
Other


*How did you hear about us?
Family
Friend
Close to work or home
Yellow Pages
Website
Health Professional


*Type of Service Requesting?
Mental Health
Alcohol and Drug
Both Mental Health with Drug and Alcohol
Gambling
Other
Do Not Know


Preferred Program:


Preferred Location:


Comments:


Client's Information.



*First Name:


*Last Name:


*Phone:


Alternate Phone:


*Date of Birth:


Address:


City:


State:


Zip Code:


Primary Care Physician:


Primary Care Clinic:


Primary Care Phone: