New Client INTAKE Form

New Client Request Form

Please complete this form to request services. Not all providers are currently accepting new clients, but once submitted, our office will contact you with available options.
Please select the services you are requesting to begin with:*

CounselingMedication Management
Who are these services for?*
This form must be completed by the individual seeking services, or by the legal guardian if the client is a minor.

Patient Demographic Information

This section is for the demographic information of the individual seeking to become a new client.
Are you the legal guardian of the client?*

YesNo
Please enter your information: (Legal Guardian)*
Patient Name*

First NameLast Name
Date of Birth*
Age:*
Gender*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Social Security #
Not required, but helpful for insurance verification and billing purposes.
Address (Mailing)*

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Information

We do NOT accept Medicare but are working on getting In-Network with them, if you have Medicare or an Insurance we do not accept, please select the Self Pay option to continue.
Do you have insurance?*

YesNo, I will be SELF PAY
Primary Insurance:*
If you do not see your insurance, please select Other.
1. Choose your Medicaid Plan Name:
OTHER Insurance Name:*
Member ID/Policy Number (Primary)*
Policy Holder*

SelfOther
Relationship to client:
Policy Holder Name:*

First NameLast Name
Policy Holder DOB*

MonthDayYear
Date
Do you have secondary insurance?*
Secondary Insurance:
2. Choose your Medicaid Plan Name:
Member ID/Policy Number (Secondary)

Do you have EAP Benefits?
Do you have EAP Benefits through your insurance that will be covering your appointments?

YesNo
Employee Assistance Program

An Employee Assistance Program (EAP) is a voluntary, work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems.
EAP Company Name: (If unsure, please be sure to provide us with EAP phone Number below - This is NOT your place of Employment)
EAP Company Phone Number:
Please enter a valid phone number.
# of EAP Sessions Approved:
EAP Authorization # (Given to you once you have initiated the sessions with your EAP Company) :

Reason For My Request
What are a few BRIEF reasons you are seeking counseling/med management?*
This helps us better understand your needs and match you with the most appropriate provider. You may keep your response brief—details can be discussed during your first appointment.
If there is any additional information you would like to add, please do so here...
Feel free to include any details you believe may help us better understand your needs or situation. This section is optional.

Provider and Scheduling Preferences (Optional)
Would you prefer a Male or Female Provider?
If accepted, is there a certain day and/or time that would be best to schedule you?
Do you know which Provider(s) you are wanting to be scheduled with?
If your are not sure, once you submit on your Intake, a member of our staff will choose a provider we think will best fit you!

Final Step: Upload Your Documents

If you upload all required documentation now, you will not need to bring these items to your first appointment. This helps us verify your information in advance and streamline your intake process.

Driver’s License (Required for legal guardians of minors)
Driver's License/I.D. (FRONT)

(if a patient is a minor, upload Guardians)
Cancelof
Driver's License/I.D. (BACK)

(if a patient is a minor, upload Guardians)
Cancelof

New Client Request Form