New Patient Intake Form (Archived)

New Patient Intake Form
- Name
  
  First NameMiddle NameLast Name
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Email
  example@example.com
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- YesNoOther
- CounselingMental Health EvaluationPsychological AssessmentPrivate AssessmentLearning Disability AssessmentInjured WorkerAutism EvaluationFitness for Duty EvaluationWorkplace Accommodations AssessmentLabor and Industries Claim
- MaleFemaleNon-BinaryOther
- EnglishSpanishOther
- Will an interpreter be needed?
- Do you have insurance? If yes, please type your name and patient ID number
- Reason for Referral*
- YesNoOther
- If Labor and Industries claim, what is the date of injury?
  
  MonthDayYear
  Date of Injury
- If this is related to a Labor and Industries claim, what is the approved diagnosis?
  Approved Diagnosis
- Claim's Manager Name
  Claims Manager Name
- Claim's Manager Phone Number
  Claim's Manager Phone NumberFormat: (000) 000-0000.
- Claim Number
  Claim number
- YesNo
- Attorney Rep Name and number
  Attorney Information
- Ability to avoid dangers/hazardsAngerAnxietyCommunity Linkage of ServicesDaily living skillsDepressionGriefHousingHygieneImpulsive BehaviorsJuvenile Justice/Court InvolvedLife SkillsMaintaining personal affairsMedication EducationNutritionalPhobia/sPhysical InjuryPRTF/Hospital DischargeSafe living situationSchool behaviorSelf-Advocacy SkillsSelf HarmSeparation IssuesSocial SkillsSubstance UseSustainable employmentTraumaTruancyWhole Health/WellnessYouth to Young Adult TransitionWork Related Injury
- Has patient ever had a psychological evaluation? If yes, please provide previous diagnoses.
- Has patient ever been hospitalized for mental health treatment? If yes, please explain
- Any additional information you would like us to know?
- Additional Documentation, Background or Medical History, etc
  
  Cancelof
- No show & Late Cancellation Policy
  
  Policy Details
  Our no-show and cancellation policy applies to missed appointments, which include:
  
  * No-show: You don’t arrive for your appointment, and you don’t reach out to cancel.
  * Late arrival: You arrive 15 or more minutes past your appointment time.
  * Late cancellation: You cancel your appointment less than 24 hours before your appointment time.
  We understand there are times when you must miss a medical appointment due to emergencies. However, missed appointments impact the flow of patients in our clinics. If you have a history of two or more missed appointments with a clinic or provider in a 12-month period, the clinic may decide not to treat or see you in the future.
  
  You can help us ensure all patients have the appointment access they need by:
  * Arriving on time for your appointments.
  * Understanding that if you arrive 15 or more minutes after your appointment time, we may
  need to reschedule your appointment.
  * Notify the clinic at least 24 hours in advance if you can’t make it to your appointment.
  You can notify our clinics of a change or cancellation by phone (509) 766-1878 or email office@danielsbrowncounseling.com.
  There will be a $95.00 No-show or late cancellation fee that you will be responsible for. Insurance will not cover this cost. After the fee is paid in full, you can reschedule your next appointment.
- I have read the missed appointment policy and agree to its terms.*
  
  Clear
- Should be Empty: