Patient Intake Form
Name of Therapist / Psychiatrist / Physician:
*
Reason for your visit
*
Please Select
Mental Health Visit
Psychological/Neurological Testing
Assessment ASD
Assessment ADHD
Assessment Learning
Other
Patient Name
*
First Name
Last Name
Date Of Birth
*
Sex:
Male
Female
Non-Binary
Email
example@example.com
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell
Please enter a valid phone number.
Format: (000) 000-0000.
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Appointment Date ***skip this part if you have not been scheduled
Parent/Guardian/Spouse (Responsible Party)
Name/Relationship
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address for billing if different than above
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information
Please upload a copy front and back of your insurance cards.
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Primary Insurance Name:
*
Policy #:
*
Policy Holder Name:
*
Policy Holder's DOB:
*
Secondary Insurance Name:
Policy#:
Tertiary Insurance Name:
Policy#:
Responsible Party Signature
I authorize the release of any medical or other information to process this claim. I understand that, although insurance may or may not cover part of my charges, I am responsible for payment, and I authorize payment of my insurance to be paid directly to the provider.
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
CONSENT FOR TELEHEALTH CONSULTATION: I understand that my health care provider wishes me to engage in a telehealth consultation. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand. By signing this form, I certify: That I have read or had this form read and/or had this form explained to me.That I fully understand its contents including the risks and benefits of the procedure(s).That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: