Adult Intake Form (Otter Creek)

Adult Intake Form
Personal Information
Referred To: *Please note - Psychiatry may be limited, if available.
Location:
Legal Last Name:
Legal First Name:
Preferred Name and Pronouns:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone:

Area CodePhone Number
Cell Phone:

Area CodePhone Number
Work Phone:

Area CodePhone Number
Ok for Message?
E-mail:
Birth Date:

MonthDayYear
Current age:
Gender on record if using health insurance:
Referred By:
PCP:
Location:
To Make an Appointment, Contact:
Phone Number:

Area CodePhone Number
Current Medication:
Current Diagnosis (if applicable):
Reason For Referral (please be specific, as this will help us connect you with an appropriate provider):
Availability (please list both days and times):
Are you seeking telehealth or in person sessions?
Do you have a preference regarding the gender of the provider?
Insurance/Billing Information
Insurance:
Phone:
Policy ID:
Group Number:
Employer:
Secondary Insurance:
Subscriber:
SSN:
Enter the message as it's shown
Is there anything else that you would like us to know?
Should be Empty:

Adult Intake Form