Intake Form (Therapeutic Counseling)

1

NameLegal Name

First Name

Last Name

2

Date of Birth

Date

3

Social Security Number

4

Birth Gender

Male

Female

6

Parent/Guardian NameIf patient is under the age of 18

First & Last Name

Phone Number

7

Phone Number

Please enter a valid phone number.

8

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

9

Email

example@example.com

10

Permission to Leave Message:Click all that apply

Text

Do not Leave a Message

Email

Voicemail

12

How would you prefer services?

Telehealth

In-person

13

Primary Care Physician Name

14

Insurance Card (Front)Please upload a photo of the front of your insurance card. Please make sure all four corners of the card are visible and that it's legible.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

Insurance Card (Back)Please upload a photo of the back of your insurance card. Please make sure all four corners of the card are visible and that it's legible.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

16

How'd you hear about us?