Intensive Outpatient Treatment Intake Form
Patient Information
Name
*
Ex: John Smith
Email
*
Phone Number
*
By providing a telephone number and submitting the form, you are consenting to be contacted by SMS text message and agreeing to our HIPAA Notice of Privacy Practices. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out of further messaging. Reply HELP for more information.
Date of Birth
*
-
Month
-
Day
Year
Home Address:
State
*
AL, MS, TN, or TX
Zipcode
*
Preferred method of contact?
*
Text, Phone call, Email, or Zoom / Facetime
Insurance Type
*
Insurance ID
*
Insurance Card
Browse Files
Drag and drop files here
Choose a file
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
Employee Wellness Program
Community Event or Health Fair
Insurance Provider Directory
Other
Which Healthcare Provider?
Which Insurance Provider Directory?
Which Community Event of Health Fair?
Which Employee Wellness Program?
Source (Internal)
*
IOP Intake Form
Services
*
Intensive Outpatient Groups
Submit
Should be Empty: