DEC Intake Form

DEC Intake Form
Client Name:*

First NameLast Name
Address:*

Street Address

Street Address Line 2

City: State / Province

Postal / Zip Code
Cell/Home Phone: *
Please enter a valid phone number.
Alternate Phone:*
Please enter a valid phone number.
Marital Status:
DOB: *

MonthDayYear
Date
Gender: *
Race/Ethnicity:
Referral Source:
Phone:
Please enter a valid phone number.
Primary Care Physician:
Phone:
Please enter a valid phone number.
Psychiatrist:
Phone:
Please enter a valid phone number.
Parent/Guardian (if applicable):
Patient/Guardian Employer:
Client’s Primary Insurance:
Policy #:
Policy Holder Name:
DOB:

MonthDayYear
Date
Secondary Insurance:
Policy #:
Reason for Seeking Services:
Appointment Reminders
Please check the box with your preferred method to be notified of your appointment date & time (Only select one option)

Reminders may be given up to 3 days in advance depending on the date of your appointment
Email Reminder:Phone Call:No Reminder
Email Reminder:
Phone Call:
Are Voicemails with Appt. Time & Date OK?:*

YesNo
Email and text are not secure forms of communication. Please do not email or text clinical information. I agree that appointment reminders are strictly a courtesy and understand missed appointments are my financial responsibility that will not be covered by my insurance. My signature below shows that I understand and agree with these terms.
Client/Guardian Signature/Print*

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Relationship to Client*
Should be Empty:

Appointment Reminders