Intensive Outpatient Treatment Intake Form
Patient Information
Name
*
Ex: John Smith
Email
*
Phone Number
*
Ex: 2814899830
Date of Birth
*
-
Month
-
Day
Year
State
*
AL, MS, TN, or TX
Zipcode
*
Preferred method of contact?
*
Text, Phone call, Email, or Zoom / Facetime
Sex
*
Please Select
Male
Female
Social Security Number
Insurance Type
*
Insurance ID
*
Insurance Card
Browse Files
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Please provide a clear front and back picture of the patient's insurance card
Cancel
of
Identification Card
Browse Files
Drag and drop files here
Choose a file
Please provide a clear front and back picture of a valid identification card for the patient
Cancel
of
Is this Patient currently enrolled at Pathway Healthcare?
*
Yes
No
Is this Patient currently enrolled in inpatient or residential care?
*
Yes
No
Discharge Date
*
-
Month
-
Day
Year
Is this Patient a referral?
*
Yes
No
Referral Information:
Referring Pathway Provider:
*
Referral Information:
First Name
*
Last Name
*
Email Address
*
Phone Number
*
Referring Facility
*
How did you hear about us?
*
How did you hear about Pathway?
*
Referral from Healthcare Provider
Google / Search Engine
Family of Friend Recommendation
Pathway Website
Psychology Today
Social Media
Employer Wellness Program
Community Event or Health Fair
Insurance Provider Directory
Other
Submit
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