Adult Intake Form
Please note: Missing information will delay the referral process
Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone:
Please enter a valid phone number.
Home Phone:
Please enter a valid phone number.
Work Phone:
Please enter a valid phone number.
Is it okay to leave a message? Please select all that apply:
*
Cell
Home
Work
None of the above
Email:
*
example@example.com
Preferred Method of Contact:
*
Cell
Home
Work
Email
Sex:
*
Gender:
*
Preferred Pronouns:
*
Current Age:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Primary Care Provider:
First Name
Last Name
Primary Care Provider Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred By:
First Name
Last Name
To Make an Appointment, Contact:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Preferred Method of Contact:
*
Phone
Email
Current Medication (if applicable):
Diagnosis (if applicable):
Reason for Referral (please be specific):
*
Insurance:
*
Policy ID #:
*
Group #:
*
Employer:
*
Subscriber:
*
Phone Number:
Please enter a valid phone number.
Secondary Insurance:
Policy ID #:
Group #:
Employer:
Subscriber:
Social Security # (only required for Medicare coverage):
Is there a particular therapist you are looking to work with? If so, please list the name(s) of the therapist(s) below:
Do you have a preference of Telehealth or in person therapy sessions?
*
Telehealth
In person
No preference
Desired frequency of sessions?
*
Weekly
Bi-weekly
Monthly
Other
Do you have a preference of a male, female or non-binary therapist?
*
Male
Female
Non-binary
No preference
What is your availability throughout the week? Please list both days and times:
*
Is there anything else you would like us to know?
Submit
Should be Empty: