_Impact Care- Intake Form

Client Name
DOB
Address
Apt
City
Zip
Phone
Work Phone
Email
example@example.com
Occupation
Language
Pregnant or Could be Pregnant:
Gender
Marital Status
SSN
Type of Insurance
Primary Care Physician
Children names
Birthdates
Referred by
Phone
Agency
Date

MonthDayYear
Date
Reason for Referral
Please indicate the person(s) that we are authorized to share your treatment information with Phone: Emergency Contact
Emergency Contact
Emergency Contact
Phone
How can we assist you and your family (client service request):
Uses and Disclosures for Health Care Operations: We will make uses and disclosures of your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc.
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty: