INTAKE FORM
Name
*
First Name
Last Name
Date of Birth
*
MM/DD/YYYY
Social Security Number
*
xxx-xx-xxxx
Primary Insurance
*
Member ID
*
If not applicable, write N/A
Please upload a photo of the front of your insurance card.
*
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Please upload a photo of the back of your insurance card.
*
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Secondary Insurance (if applicable):
Member ID (if applicable)
CLIENT INFORMATION
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
You will receive Text reminders for appointments. If you do not want to receive these reminders, please select below
*
I choose to opt-out of receiving appointment reminders from CBHC.
List any allergies (food, medication, other)
Examples: Aspirin, Penicillin, Ect.
Sex
*
Please Select
Male
Female
Non-Binary
Martial Status
*
Single
Married
Divorced
Other
Race
*
White
African American
Arab/Middle Eastern
Asian
Hispanic
Other
Language
*
English
Russian
Nepali
Arabic
Spanish
Other
POA/GUARDIAN (If Applicable)
If you have a POA or Guardian you must enter this information. Please bring documentation of your guardianship to your first appointment.
Do you have a POA or Guardian?
*
Please Select
Yes
No
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
POA/Guardian's relationship to client:
Parent
Spouse
Child
Other
EMERGENCY CONTACT
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact's relationship to client:
*
Parent
Spouse
Child
Other
Any history of psychiatric hospitalizations? This includes substance use treatment and partial hospitalization.
*
Yes
No
If "yes" please list the dates and reason for the psychiatric hospitalizations. Please also list any treatment changes that were made. If "no" put "N/A".
*
PHARMACY INFORMATION
Primary Pharmacy Name
*
Primary Pharmacy Location
*
Other Pharmacy Name
Other Pharmacy Location
Do you have a Psychiatric Advance Directive or a Healthcare Proxy?
Yes (if "Yes" please upload or provide a copy at your next appointment)
No
Psychiatric Advance Directive Upload
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Healthcare Proxy Upload
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Accurate and True Information:
*
I hereby attest that all the information I have provided is accurate and true.
Client Signature (or POA/Guardian)
*
Today's Date
*
-
Month
-
Day
Year
Date
Continue
Continue
FOR STAFF USE ONLY
Signature of CBHC Staff Member
*
Today's Date
*
-
Month
-
Day
Year
Date
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