Client Informed Consent

Client Intake Forms

Anchored in Hope Counseling Services LLC. 33 Beaver Drive, Suite L Dubois, PA 15801 (814) 299-7771
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*

Area CodePhone Number
Leave a Message?*

YesNo
Secondary Number

Area CodePhone Number
Leave a Message?

YesNo
Email*
example@example.com
Emergency Contact*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
By listing this person, I authorize the release of necessary information listed person in the event of an emergency or the inability to contact me for scheduling or treatment purposes.
If Minor, Parent/Guardian

First NameLast Name
Phone Number

Area CodePhone Number
Referring Person or Physician

Insurance/Payment Information
Insurance Company*
Policy Number*
Group Number
Subscriber Name*

First NameLast Name
Relationship to Subscriber*
Subscriber Date of Birth*

MonthDayYear
Date
Subscriber Phone Number*

Area CodePhone Number
Secondary Insurance Company
Policy Number
By offering this information, I agree to allow this practice to release necessary information to the above insurance company and insurance subscriber to submit billing claims on my behalf.

Who currently resides with you both adults and children? (If you live alone answer N/A)*

Any Children that do not live with you?

Tell us about your family:

Client Intake Forms