Client Intake Request Form

Client Intake Request Form
Client Name

First NameLast Name
Birth Date

MonthDayYear
Age
Parent / Guardian (if client is a minor)
Provide the contact information for the individual responsible for scheduling appointments
E-mail
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reason for referral
Details about your issue
What is your primary goal for counseling
Insurance ( please note we’re in process of credentialing with IL Mediciad and will offer sliding scale until were approved)

CignaMO MedicaidTricare EastMedicareAetnaUHCMultipanHumanaHealthlinkFLOUISH
Income Based Sliding Scale - Based on availability and scheduled with a graduate intern or entry level therapist.

$25 intern$35 therapist
Self Pay

$50
Availability Check all that apply :

Morning: 9am-12pmAfternoon 12pm - 4pmEvening 5pm-8pmWeekendsFlexibleOther
Therapist Preference

MaleFemaleNo preferenceNonbinary
Specific Therapist
Please email the following to billing@thecommunityreach.org
- Front and back copy of your insurance card
- Photo ID (Parent if client is a minor)
Signature

Clear
Should be Empty: