Intake JotForm

Brief Intake Form

This is a HIPAA compliant form that includes symptoms, consent policies. Completion of this form does not guarantee a treatment relationship is established. The more thorough the information provided, the better we will be able to assist you. If you are having an emergency, please contact 911 immediately
📌 Priority Notice

Priority is given to patients who complete the form thoroughly. Incomplete submissions may delay scheduling and insurance verification. If partial incomplete information is provided, we may not be able to reach out in a timely manner.
Patient Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex (on file with insurance)*

MaleFemale
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Current address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you find us?*
Referring Provider
Payment method*

InsuranceSelf-pay

Insurance Information

(Required to start the verification of benefits)
Primary Insurance Plan *
Member ID*
Member ID (OLD numbers only)
Upload a picture of the FRONT of your insurance card here:

Must be submitted to consider appointment
Cancelof
Upload a picture of the BACK of your insurance card here:

Must be submitted to consider appointment
Cancelof
Relationship to Policyholder*
The policyholder is the person who owns the insurance plan. This may be you, a parent, a spouse, or someone else whose insurance you're using for your care.
Policyholder Name*

First NameLast Name
Policyholder Date of Birth*

MonthDayYear
Policyholder Sex (on file with insurance)*

MaleFemale
Policyholder Address

Same as my addressDifferent address
Policyholder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policyholder phone
Please enter a valid phone number.
Do you have a secondary insurance policy?*

YesNo
Secondary Insurance Plan *
Member ID*
Upload a picture of the FRONT of your insurance card here:

Must be submitted to consider appointment
Cancelof
Upload a picture of the BACK of your insurance card here:

Must be submitted to consider appointment
Cancelof

Appointment Details & Consent
Desired Appointment Time*
Appointment Type*

TelehealthIn-Office Appointment
You will receive a confirmation via email and/or text message if we are able to schedule your appointment at the requested date and time. If not, our team will contact you to provide alternative availability.
I confirm all information in this form is true and accurate. I also understand that all data in this form will be strictly confidential. I have reviewed and agree to the consent policy and the release of information policy linked blow.

We may share limited contact details with third-party software providers to facilitate scheduling, billing, or other care-related tasks. Your protected health information (PHI) remains stored and processed on HIPAA-compliant platforms in accordance with federal regulations.

If you have any questions or concerns, please call/text us at 910-310-8376 or email at info@psychwellnow.com.
Your Signature*

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Brief Intake Form