Forever Young Counseling

Forever Young Counseling

New patient intake Form
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birthday*

MonthDayYear
Date
Is this a mobile phone?*

YesNo
Would you like text reminders?*

YesNo
Have any other counselors or therapists worked with the patient?
Please list all providers
Has the patient ever attempted suicide?*

YesNo
If yes, how many times and date of last attempt (or best guess at date)?

If the patient is a minor please fill this section out
Parent/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Insurance

If using Montana Healthy Kids or Medicaid a pic of the card will do
Will you be using insurance? If so, please take a photo of your insurance card.*

YesNo
Primary insurance company name
Group/policy number
Insurance company phone number
Insured person's name
Insured person's social security number or ID number
Insured person's date of birth
Insured person's relationship to patient
Insured person's employer
Front of insurance card
Back of insurance card

If the patient is a minor please fill this section out