EMR - PRE INTAKE
Does the lead know who we are / is interested in our services?
Please Select
Yes
No
Is the lead a resident of NJ?
Please Select
Yes
No
Other State:
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other City:
Does the lead have a valid insurance?
Please Select
Yes
No
Is the lead willing to pay out of pocket?
Please Select
Yes
No
Other Insurance:
JoT Form Name
Clinic
HubSpot Record ID
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Next
Leadsource
*
Please Select
Google
Facebook
Instagram
Youtube
TikTok
ZocDoc
ZocDoc Call ins
Psychology Today
Mental Health Match
Good Therapy
Word of mouth
Pickleball
Sam Referal
Referral - Therapist
Referral - Employee
Referral - Friend
Insurance Website
Maps / Show Me Local
Other
Name
*
First Name
Last Name
Email
*
Phone Number
*
phone2 (if client wants to change their number)
Please enter a valid phone number.
Date of Birth
-
Month
-
Day
Year
Location
Other Leadsource
Agent Name
*
Intake type
*
Please Select
Regular intake
TMS intake
Please provide details regarding the referral
Send intake by
Email
Text
Notes
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Should be Empty: