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 *

Male Female Transmale Transfemale Genderqueer Neither exclusively male nor female
Emergency Contact *

Name Phone Number
Sexual Orientation *

Straight Lesbian Gay Bisexual
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
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 Ohio Health Cigna UMR Molina Caresource Medical Mutual Optima - Ohio Health Optum - UHC Tricare Medicaid Medicare
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
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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