COGNIZANT BEHAVIORAL HEALTH SERVICES - PATIENT INTAKE FORM
Today's Date
*
/
Month
/
Day
Year
Date
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Patient Gender
*
Age
*
Emergency Contact Name
Emergency Contact Phone Number
Address
*
Address
Street Address Line 2
City
State
Zip
Cell Phone
*
Home Phone
Patient E mail
*
example@example.com
Work Status
Employed
Unemployed
Retired
Disabled
Employer
Occupation
Marital Status
Single
Married
Divorced
Widowed
Separated
Domestic Partner
INSURANCE PRIMARY
Subscriber Name
*
Subscriber's date of Birth
*
/
Month
/
Day
Year
Date
Relationship to Patient
Subscriber's Phone Number
*
Insurance ID Number
*
Group Number
Behavioral Health Insurance Carrier (may be different than medical)
*
Please include the phone number for provider to call for mental health coverage (Located at back of the card)
Subscriber Employer
Reason for Appointment
Insurance Card Front
Insurance Card Back
Preview PDF
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