New Client Intake Form

Please Note

We cannot answer calls about a potential client until we receive this intake form

Name of person filling out this form *

Relationship to client *

Date *

Demographics

Client Name *

Date of Birth *

Age *

Date of Birth *

Client Gender *

Male Female Other

Other (Please Specify)

Grade Level or Highest Degree *

School Name

Client Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Client Cell Phone (if a legal adult) *

Client Home Phone

Client Work Phone (if applicable)

Client Email *

example@example.com

Family Information

Parent/Guardian (1) Name

Relationship to Client

Phone Number

Please enter a valid phone number.

Email

example@example.com

Parent/Guardian (2) Name

Relationship to Client

Phone Number

Please enter a valid phone number.

Email

example@example.com

Does one or both parent(s) have guardianshipover the client?

Yes No

If Yes, Who?

Medical Information

Primary Care Physician (PCP) Name

PCP Phone Number

Please enter a valid phone number.

Psychiatrist Name

Phone Number

Please enter a valid phone number.

Other Provider Name

Other Provider Phone

Specialty

Payment for Services

Out of Pocket

Are you paying for services out-of-pocket (will not be billed to insurance)? (If yes, disregard insurance and county sections) *

Yes No

Medical Insurance Information

Insurance Company Name

Member ID

Group Number

Policyholder Name

Policyholder DOB

Policyholder Relationship to Client

Policyholder Employer

Policyholder Address (if different from client's)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Please upload a picture of your insurance card (Front)

Please upload a picture of your insurance card (Back)

Please upload current photo of client

Insurance Company Phones

Behavioral Health Phone #

Provider Phone

Pre-certification Phone

Insurance Company Claims Address

City

State

Zip

County Funding

County

Caseworker Name

Caseworker Phone

Please enter a valid phone number.

Note: If you are funded by Franklin County, scheduling will not occur until after we receive an authorization from your caseworker to cover services. Please alert your caseworker about seeking services and inquire about a pre-authorization.

Reason for seeking services (current problems / challenges) *

Client Current Diagnosis or Diagnoses *

If you were referred to Amigo Family Counseling, LLC, who referred you?

Business Name

Phone Number

Specialty

If you were not referred, how did you hear about us

If other, please specify

If applicable, who were you referred to see at Amigo Family Counseling, LLC?

If known, what services are you seeking at Amigo Family Counseling, LLC (Select all that apply) *

Group Responsability Social Therapy(RST) Program Psychological Testing (specify below) Diagnostic Testing (to determine or ruleout an Autism Spectrum Diagnosis) Individual Psychotherapy Family Psychotherapy The Creative Social Arts Program / ActingWorkshops Other (specify below)

Other

Psychological Testing For

Please Note

Follow-up phone calls for intakes are generally made Tuesday - Thursday, 6:30 pm - 9:00 pm. The Phone number associated with follow-up calls is (614) 310-1234. As some of our staff are making phone calls outside of normal office hours the Caller ID may read "unknown" or "private."

New Client Intake Form

Please Note

Demographics

Family Information

Medical Information

Payment for Services

Out of Pocket

Medical Insurance Information

Insurance Company Phones

County Funding

*Please Note*

Please Note