NEW CLIENT INTAKE FORM (Bridge to Restoration Therapy Services)

1
Client Name InformationPlease enter ONLY the client's name information here. (If you are completing this form on behalf of a client, there will be space in another field to enter your information.)
FIRST Name
MIDDLE Name
LAST Name
Preferred Name / Nickname
2
Relationship to Client* This field is required.If you are the client, select "Self" in the 'Person Completing This Form' field and move on to the Date of Birth section. if you are completing this form on behalf of a client, please complete all the fields that apply in this Relationship section.
Please Select
Please Select
Self
Parent
Guardian
Spouse
Social Worker
Other*
Person completing this form. (If you are the client, select Self.)
If you selected "Other," state your relationship to client here
Name of person completing this form (if not client)
3
Client Date of Birth* This field is required.
Date
Month
Day
Year
4
Phone Number* This field is required.
Please enter a valid phone number.
5
Email Address* This field is required.
example@example.com
6
Photo Identification (Drivers License, State ID, or Similar)* This field is required.PLEASE NOTE: This is required, and failure to provide a government-Issued photo ID will delay the process)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
7
Home AddressPlease complete this section if the client address is different from the address on your photo identification. (Skip if the same.)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Health Insurance / Payment InformationPLEASE NOTE: Failure to provide health insurance information will delay the process of getting started as a new client. (If you will be paying directly/not using health insurance, select the "No Insurance / Direct Pay" option in the drop-down list.) We do not currently accept Medicare.
Please Select
Please Select
No Insurance / Direct Pay
Aetna
Blue Care Network of Michigan (BCN)
Blue Cross Blue Shield
Blue Cross Complete of Michigan
McLaren
Medicaid (Michigan, general)
Meridian
Molina
Priority Health
United Healthcare
*Other
Insurance
If you selected Other, please explain here. (Note: the insurances listed are the providers we currently accept. If you have an EAP or other payment provider/arrangement, here is where to put those details.)
Primary Insured Name. (type "Self" if client is the insured)
9
Health Insurance Carrier Name* This field is required.PLEASE NOTE: Failure to provide health insurance information will delay the process
10
Health Insurance ID/Account Number* This field is required.PLEASE NOTE: Failure to provide health insurance information will delay the process
11
Primary Person Insured Name & Date of Birth* This field is required.PLEASE NOTE: Failure to provide health insurance information will delay the process
12
Front of Health Insurance CardPLEASE NOTE: Failure to provide health insurance card images will delay the process
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
13
Back of Health Insurance CardPLEASE NOTE: Failure to provide health insurance card images will delay the process
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
14
Please briefly explain why you are seeking therapy:
15
Hospitalizations* This field is required.Please list any hospitalizations in the past 90 days and include dates
Huge
Large
Normal
Small
Ok
Ok
16
Suicidal Ideation* This field is required.Do you have any history of (and or current) suicidal thoughts or attempts?
YESNO
17
Virtual or In-Person Appointments Preference?
Please Select
Please Select
Virtual
In Person
Both
No preference
18
Preferred Days and Times for Sessions:
19
Therapist Preference:* This field is required.(All Therapist bios are available on our website)
Please Select
Please Select
Crystal Barnett, LLMSW
DeRae Chapman, MA, TLLP
Dwayne Johnson, LLMSW (virtual appointments only)
Hasina Bankston, LMSW (couples/marriage counseling only)
Dr. Patricia Keller, PhD (virtual appointments only)
Tasha Ledesma, LMSW
Tarien Williams, LLC
Dr. Tracy Newbern, PhD (virtual appointments only)
Vivian Keller, LMSW
No Preference
20
How did you hear about us?* This field is required.
Please Select
Please Select
PsychologyToday
Word of Mouth
Google
Our Mental Health Collective/Mental Health Clinicians of Color
A Bridge to Restoration Client
A Friend or Family Member
Care Solace
Church
Employer/EAP
Facebook
Health Bar
Health Insurance Provider/Directory
Instagram
Mosaic Counseling
Network180
Our House of Blessings
Pine Rest Christian Mental Health Services
Probation Officer
Social Worker
Other
21
Referred By
22
What is the best way to contact you?* This field is required.(Check all that apply)
Phone
Text
Email
23
Question/Concerns/Any Additional Information:
Should be Empty: