Ingage Life 4 Tomorrow Intake Form

Client Intake Form
Personal Information
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Work Phone*

Area CodePhone Number
E-mail
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date*

MonthDayYear
Gender*
Marital Status
How were you referred to our office?

Emergency Medical Information
Physician Name

First NameLast Name
Office Phone

Area CodePhone Number
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*
Emergency Contact Phone Number*
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I plan to use my cardI want to pay cashInsurance (Virginia Residents Only)
AetnaAnthemHumanaMedicareMedicaidOpitima
Policy Number

Notice of Privacy Practices
I have Receive Notice of Privacy Practices (Client Signature)

Clear
Date

MonthDayYear
Date
I have Received Notice of Privacy Practices (Parent/Guardian Signature)

Clear
Date

MonthDayYear
Date

Notice of Client Rights
It is your right to:
1. Retain your legal rights as provided by state and federal law.
2. Receive prompt evaluation and treatment or training about which you are informed insofar as you are capable of understanding.
3. Be treated with dignity as a human being and be free from all forms of abuse.
4. Not be the subject of experimental or investigational research without your prior written and informed consent or that of your authorized representative.
5. Be afforded an opportunity to have access to consultation with a private physician at your own expense, and in the case of hazardous treatment or irreversible surgical procedures have, upon request, an impartial review prior to implementation, except in case of emergency procedures required for the preservation of your health.
6. Be treated under the last restrictive conditions consistent with your condition and not be subjected to unnecessary physical restraint and isolation.
7. Be allowed to send and receive sealed letter mail.
8. Have access to your medical and mental records and be assured of their confidentiality, but notwithstanding other provisions of the law such a right shall be limited to access consistent with your condition and sound therapeutic treatment.
9. Have the right to an impartial review of violations of the rights assured under this section and the right to access to legal counsel.
10. Be afforded appropriate opportunities, consistent with your capabilities and capacity to participate in the development and implementation of your individualized services plan.
Name

First NameLast Name
Date

MonthDayYear
Client Consent or Objection to Participation in the Assessment Process

By our signatures below, we agree to participate in the assessment process. We have been informedthat we may revoke our consent at any time.
Consent
Child/Client

Clear
Date Signed

MonthDayYear
Date
Parent

Clear
Date Signed

MonthDayYear
Date
Authorized Representative

Clear
Date Signed

MonthDayYear
Date
Objection
Child/Client

Clear
Date Signed

MonthDayYear
Date
Parent

Clear
Date Signed

MonthDayYear
Date
Authorized Representative

Clear
Date Signed

MonthDayYear
Date
Reason for Objection
Should be Empty:

Client Intake Form

Personal Information

Emergency Medical Information

Notice of Privacy Practices

Authorization for Release of Infomation

Initial 24-Hr Service Plan

Notice of Client Rights

Client Consent or Objection to Participation in the Assessment Process

Consent

Objection