Client Intake Form
Please complete Required Sections, the remainder of sections can be completed during the assessment if you choose to wait. A reminder
Client Name
*
First Name
Last Name
Client Birth Date
*
-
Month
-
Day
Year
Date
Client Gender
Please Select
Female
Male
Non-Binary
Transgender
Prefer Not to answer
Client Soc Sec Number
*
Client/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you agree to receive text messages from Live Up Behavioral sent from one of the following numbers (419) 775-3835 or (419) 239-2113.Message frequency varies and may include messages for appointments and treatment updates. Message and data rates may apply. Reply "STOP" at any time to end or unsubscribe and no further messages from Live Up Behavioral Health . For assistance, reply "HELP" or contact support at (888) 754-8387, foxt@liveupbh.com, or www.liveupbh.com
Yes, I agree to receive text messages from Live Up Behavioral Health sent from(419) 775-3835 or (419) 239-2113
No, I do not want to receive text messages from Live Up Behavioral Health, no messages will be sent.
Client Martial Status
Please Select
Married
Never Married
Partnered
Widowed
Divorce
Contact Email
*
Client Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Services Seeking
Behavioral Health
Behavioral Respite
Both
Are You Currently
Working
Unemployed
Retired
Student
Disabled
Referred by:
Insurance Company
Internet Search
Word of Mouth
Advertisement
Other
Reason fo Referral
*
Were you referred by someone from Live Up Behavioral Health? If so please let us know who:
First Name
Last Name
Primary Insurance Provider
*
Please Select
Caresource
Buckeye Health Plan
United Health Community Plan
Molina Healthcare
Amerihealth Caritas
Anthem Blue Cross Blue Shield
Humana Healthy Horizons
Aetna Better Health
Other Medicaid Provider
Primary Insurance Identification Number
Are you currently receiving psychological services, professional counseling, psychiatric services,or any other mental health services?
*
Please Select
yes
no
Have you been psychiatrically hospitalized in the past?
*
Please Select
yes
no
Emergency Contact
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Release of Information
Please complete now
Records released pursuant to this authorization may inclide information concerning testing or diagnosis
*
yes, I agree and look forward to having packet of information.
no, I would like further information prior to assessment
Please select one of the following options: I am giving informed consent of assessment, treatment, and general services as client or guardian.
*
yes
no
Please select one of the following options: About telehealth services:
*
Yes, I give consent to services including Telehealth
Yes, I give consent to services but do not wish to give consent for telehealth
Acknowledgement of Clients Rights and Confidentiality
*
yes
no
By signing this document, I agree to the following documents that will be presented by theTherapeutic Behavioral Specialist upon beginning treatment. 1. Informed consent of assessmentand treatment. 2. Understanding of privacy practices 3. Telehealth consent 4. Authorization to BillInsurance 5. Release of information 6. Reasonable Transportation Permission
*
yes, I agree and look forward to having packet of information
no, I would like further information prior to assessment
Client/Guardian
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: