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CLIENT INTAKE FORM
Please Complete All 3 Parts Of The Form Below & Submit
CLIENT INFORMATION
Full Name
*
Date Of Birth
*
Address
*
City
*
State
*
Zip
*
Email
*
Phone Number
*
Emergency Contact
*
Submit
INSURANCE INFORMATION
Insurance Provider
*
Policy/Medicaid ID
Subscriber Name
Group Number
Relationship
(On Back Of Card)
Referring Person/Agency
Phone Number Of Referral
Email
*
Submit
CLINICAL INFORMATION
Presenting Issues/Concerns (Check All That Apply)
*
Required
Anxiety
Depression
Trauma/PTSD
ADHD/Behavioral
Family Conflict
School Problems
Substance Use
Anger Management
Grief/Loss
Other
Services Requested
Individual Therapy
Family Therapy
School-Based Counseling
Diagnostic
Assessment
Other
Is The Client Currently In Crisis Or At Risk?
If Yes, Please Explain
List Below Who You Are Referred By (If Self Referral, Write Self)
Reason For Referral
Submit
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