New Patient Intake Form

New Patient Intake Form

Information about Person Completing Referral
Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Individual Information
Name

First NameLast Name
Date of Birth

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is Individual aware of this Referral?

YesNoOther
Type of Service(s) Needed (Select all that Apply)*

CounselingMental Health EvaluationPsychological AssessmentPrivate AssessmentLearning Disability AssessmentInjured WorkerAutism EvaluationFitness for Duty EvaluationWorkplace Accommodations AssessmentLabor and Industries Claim
Individual Gender*

MaleFemaleNon-BinaryOther
Individual Primary Language

EnglishSpanishOther
Will an interpreter be needed?
Do you have insurance? If yes, please type your name and patient ID number
Reason for Referral*
Is Patient already working with a social worker or claims manager?

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 Number
Claim Number
Claim number
Is the patient working with an attorney?

YesNo
Attorney Rep Name and number
Attorney Information
Select all applicable challenges below for the Individual referred (check all that apply)

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.*

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