INTAKE

INTAKE
First, please tell us a little about yourself.

This information will be kept confidential and helps us ensure were able to provide you with care.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Now, we have a few questions about your mental health history.
Our Promise

We’ll never share your personal information with anyone without your permission.

We follow HIPAA regulations, so your responses are always secure.

Client History.
Is this your first time seeking care for a mental health problem?*

YesNo
Are you currently taking any medication to manage a mental health problem?*

YesNo
In the past six months, have you been hospitalized as a result of a mental health, drug or alcohol problem?*

YesNo
Do you feel like you are at risk of killing yourself?*

YesNo
If you or someone you know is in crisis, call 911 or the National Suicide Prevention Hotline at 1-800-273-8255 right away.

Insurance
Do you have health insurance?*

YesNo
Who is your Insurance Provider?
If you do not have insurance please select the option: No Insurance / Self Pay
What is the name of the insurance? (when Other is selected)
Your name as it appears on your insurance*

First NameLast Name
Patient's relationship to subscriber*
Primary Subscriber

First NameLast Name
Primary Subscriber's Date of Birth

MonthDayYear
Member ID*
Group ID*
Insurance Card : Upload photo of FRONT of insurance card
Insurance Card : Upload photo of BACK of insurance card
Should be Empty:

First, please tell us a little about yourself.