Client Intake Form

Intake Form
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Employment*
Referral Name

First NameLast Name
Work/School Hours

Hour Minutes

AM/PM Option
Work/School Hours

Hour Minutes

AM/PM Option
Home Phone
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Preferred Method of Contact

E-mailHome PhoneCell Phone
What are your favorite Hobbies?
Emergency Contact Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Relationship
Insurance Information
Do you have Medicaid, a commercial/employer insurance plan, or no insurance?*

MedicaidCommercial/employer planNo insurance
Medicaid Provider (Aetna, Molina, etc.)
Medicaid Number #
Insurance Provider (Aetna, Molina, BCBS, etc.)
Group Number (employer plans)
Policy Number
Please upload a picture of your insurance card (front and back).

Cancelof
Please upload a picture of your (or the guardian's) valid I.D.

Cancelof
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
If you do not currently have health insurance, please contact one of the following resources for assistance with low-cost or no-cost health coverage:

Community Health Choice – Health Navigators (medicaid application assistance)
4888 Loop Central Drive, Suite 600, Houston, TX 77081
Hours: Monday–Friday, 8:00 AM–5:00 PM
Phone: 1-833-840-0573

Community Family Centers – Gold Card Application Assistance
7524 Avenue E, Houston, TX 77012
Hours: Monday–Friday, 8:00 AM–5:00 PM
Phone: (713) 923-2316
Website: www.communityfamilycenters.org

* You will need to have completed a health insurance application before we can begin assisting you. If you need help navigating this process, please call our office at 346-209-5256 for support.
Medical History
Primary Physician Name
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
SSI # (If Applicable)
Are you currently taking prescription medication?

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone
Format: (000) 000-0000.
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Are you currently in any IOP or PHP programs?

YesNo
Please specify:
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
Mental Health History
Why you are seeking treatment?
What do you expect from this counseling (if needed)?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Therapist Name

First NameLast Name
Reason for seeking help
Average hours of sleep per night
Do you prefer conducting sessions in person, virtually, or a mix of both?*

In personVirtualBoth
Please describe any other experiences you have had problems with
Additional comments or concerns
A mental health assessment (CANS/ANSA) helps your case manager understand your current needs, strengths, and goals so we can create the best care plan for you.
The assessment usually takes about 45–60 minutes and can be completed in person or virtually
Would you like your Mental Health Assessment to be conducted in person or virtual?*

VirtualIn Person
What days in the next 7 days work best for you to complete your assessment?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
*Your signature below indicates that the information you have provided above is truthful.
Date

MonthDayYear
Date
Signature
Should be Empty:

Intake Form

Emergency Contact Information

Insurance Information

Medical History

Mental Health History