Intake Form

Intake Form
Preferred Name *
Legal Name *

First Name Last Name
Date Of Birth *

Month Day Year
Date of Birth
Current *

Month Day Year
Date of Birth
Age *
Marital Status *
Gender *

Male Female
Gender Identity *
Emergency Contact *

Name Phone Number
Sexual Orientation *
Race *
Email *
Primary Contact Phone *

Area Code Phone Number
Okay to leave message?

Yes No
Serenity Location *
New Albany Therapist *
Columbus Therapist *
Annex Therapist *
Westerville Therapist *
Dublin Therapist *
Serenity Therapist *
Cornerstone Academy Therapist *
Tele-Therapy Therapist *
Wellness Center Therapist *
Appointment Time Preferences: *

Mornings Afternoons Evenings Saturdays Anytime
Who Is the counseling for? *

Child Adolescent Adult Couple Family Group Therapy
What is this in relation to? (select all that apply) *

Abuse/Therapy ADHD/ADD Adjustment Issues Addiction/Type Alcohol/Substance Use/Abuse Anger Management Anxiety Bipolar Chronic Illness/Pain Mgt Court Ordered Cutting/Mutilation Death/Dying Issues Depression Divorce/Separation Issues Domestic Violence Eating Disorder Grief/Loss Infidelity Life Transitions Men Issues Parenting Relationship Issues Self-Esteem/Self-Worth Stress Management Suicide Thoughts/Feelings Trauma/PTSD Deaf/Hard of Hearing Transgender School Issues Behavioral Problems
Primary Insured Member Information:
Private Pay

Yes No
EAP

Yes No
Cornerstone Academy

Yes No
Primary Health Insurance

Aetna Anthem Buckeye Health Plan Medical Mutual Dennison University Ohio Health Cigna UMR Molina Caresource Medical Mutual Optima - Ohio Health Optum - UHC Tricare Medicaid Medicare
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
Secondary Health Insurance

Aetna Anthem Buckeye Health Plan Medical Mutual Ohio Health Cigna UMR Molina Caresource Medical Mutual Optima - Ohio Health Optum - UHC Tricare Medicaid Medicare
Subscriber Name:   *
Subscriber DOB:   Date*
Subscriber Address:   Street Address*      City*   State*   Zip*
Relationship To Client:   *
Relationship to Client? *

Self Parent Spouse
Date Of Birth

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
I Authorize Serenity-BHS to check benefits on behalf of the client seeking counseling.
Member ID# *
Group # *
Provide Copy Of Insurance Card

Browse Files

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Do you Authorize? *

Yes No
Enter Initials *
Client Name *

First Name Last Name
Preferred Name *
Additional Information
Who referred you to us? *

Cornerstone Academy Health Insurance EAP Google Yelp Friend
Please verify that you are human *
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