DELTA PSYCHOLOGICAL & NEUROBEHAVIORAL
SERVICES INQUIRY
DATE
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Therapist:
*
DX CODE:
Client Name:
*
DOB:
*
Gender
*
If minor child: Parents' names:
Address:
*
Cell Phone: (include both parents)
*
Format: (000) 000-0000.
Email address: (include both parents')
*
Responsible Party
*
DOB
*
Relationship
*
Address (if different than above)
Is there someone we should contact in case of emergency?
Referral Source
Referral information received?
Yes
No
INSURANCE INFORMATION
Insurance Company
*
Policy Holder
*
DOB
*
Employer
*
Contract #
Group #
Coverage codes:
SECONDARY
Insurance Company
Policy Holder
DOB:
Employer
Contract #
Group #
Coverage codes:
INSURANCE VERIFICATION
Verified benefits with:
Phone
Format: (000) 000-0000.
By/Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mental health benefits?
Authorization Required?
Deductible
Copay
Yearly max:
Verified benefits with
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
By/Date:
Mental health benefits?
Authorization Required?
Deductible
Copay
Yearly max?
Reason for contacting our Clinic
Appointment preference: In Person (explain that conditions may warrant Telehealth)
Telehealth: FaceTime(Apple)/Google Duo(Android); Doxy.me; Phone; Other:
Intake appointment with
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
PSYCHOSOCIAL IS:
Printed off website
Mailed
Will client be faxing/emailing forms back?
example@example.com
Date/Initial when received:
SERVICE CONTRACT, CONSENT FOR TREATMENT, FEE AGREEMENT have been completed, scanned and emailed?
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Initials
*
Preview PDF
Submit
Should be Empty: