Intake Form
Name
*
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Parent/Guardian Name (if patient is a minor)
First Name
Last Name
Emergency Contact Name
*
Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Do you have insurance coverage?
*
Yes
No
Insurance Company
Insurance ID#
Group #
Name of Insured
Relationship to Patient
Employment Status:
*
Full time
Part time
Disabled
Retired
Homemaker
Student
Unemployed
Reason you are seeking services:
In one sentence or less, briefly describe why you are seeking counseling
Have you ever had counseling before?
Yes
No
If yes, when (MM/YYYY)
Submit
Should be Empty: