Outpatient Intake Form - Brightside Family Services

Outpatient Client Intake Form

Please complete and submit this form. An email with your responses will be automatically be sent to the email address provided for your own records. You can expect to receive a response to your inquiry within two business days. Thank you for your interest in our services. We look forward to working with your family.

IIC Name:

In or Out Of Network:

Copay:

How Much Does Insurance Pay?

Section A - General Information

Client/Patient Name:*

Client/Patient DOB:*

Name and Relationship of Individual Completing This Form if other than Client/Patient:

E.g., Mary Smith - mother

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone #1:*

Please enter your primary phone number.

Phone #2:

Please enter an alternate phone number, if applicable.

Email Address:*

example@example.com

Presenting Problem:*

Medical Conditions:

Current Medications:

Psychiatric History:

Other Important Information to Note:

Previous Counseling Experience:*

YesNo

Section B - Family History

Have any of the patient's blood relatives (biological parents, grandparents, siblings, aunts, uncles, or close cousins) experienced the following? Please specify which relative.

	Yes	No	Relation and any remarks
Anxiety:
Attention problems:
Hyperactivity:
Developmental disorders:
Substance abuse:
Depression:
Other significant mental illness or disorder:
Genetic syndromes:
Other:

By completing this form, my signature indicates that the information provided is true and accurate. If the cilent is a minor, I certify that I have legal authority to authorize treatment.

Form completed by:*

Today's date:*

Signature:*

Section C - Insurance Information

Behavioral Health Insurance Company:*

If no insurance, please enter n/a for this entire section

Policy #:*

Group #:*

Name of Insured:*

DOB of Insured:*

Employer:*

Photo of Your Insurance Card:

Both front and back pictures are preferred

Section D - Consent to Treatment

I do hereby seek and consent to take part in the treatment by a designated therapist from Brightside Family Services. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in the process.

I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist.

I am aware that I may stop my treatment with this therapist at any time. I understand that I will still be responsible for paying for all services previously rendered. I understand that even if I am mandated to attend therapy, services with this particular provider are voluntary, and I can seek services elsewhere to meet my obligations.

I know that I must call my therapist to cancel an appointment at least 24 hours before the time of the appointment. If I fail to do so, I will be charged for that appointment.

I am aware that if my insurance is being billed for these services, an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. I understand that I am responsible for notifying the therapist of any changes to my insurance. I also understand that I am responsible to pay for services I have received if my insurance company denies the claim.

My signature below shows that I understand and agree with all of these statements.

Today's Date:*

Your Name:*

Your Signature:*

Youth may sign in place of Parent/Guardian if age 18 or over

Form Folder Name