Pathway Healthcare Intake Form

1

Let's get started!* This field is required.Which option best describes you?

Referring ProviderNew Patient

2

Patient Info:* This field is required.

First Name

Last Name

Email Address

Phone Number

Zipcode

Preferred Method of Contact

3

Patient Date of Birth* This field is required.

Date

4

Sex* This field is required.

Male

Female

Undisclosed

5

Will insurance be used?Click next if unsure

YESNO

6

Are you able to upload an current insurance card picture?* This field is required.

YESNO

7

Terms and Conditions* This field is required.Please agree to our T&Cs and sign before uploading

8

Signature* This field is required.Signing below means you agree to provide this sensitive information

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9

Upload Picture* This field is required.Please provide a clear front and back picture of insurance card

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

10

Name of insurance being used?* This field is required.

11

Member IDHit next if you are unsure.

12

Payer IDHit next if you are unsure.

13

What services are required?* This field is required.Choose all that apply

Intensive Outpatient Treatment

Psychiatry

Treatment for Substance Use Disorder

Individual Therapy

Family Therapy

Group Therapy

14

Would you consider telehealth?* This field is required.

YESNO

16

How did you hear about Pathway?* This field is required.

Referral from Healthcare Provider

Insurance Provider Directory

Family or Friend Recommendation

Psychology Today

Google / Pathway Website

Social Media

Community Event or Health Fair

Employer Wellness Program

Other

17

Which provider referred you?

18

What is the name of your employer?

19

Which social media platform?

20

Referral Info:* This field is required.We want to say thank you!

First Name

Last Name

Email Address

Phone Number

Referring Facility