Interest Intake Form
Please complete this form for interest in services. Once this form is complete you will receive a follow up call to schedule your assessment for services. Talk to you soon!
Clients Name
First Name
Last Name
Client Information
Phone number
Social Security Number to verify insurance
Date of Birth
Email
Guardian's Name (if client is minor)
First and Last Name
Phone number
Clients Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First and Last Name
phone number
Relationship
Clients Insurance Carrier
Insurance Name
Group Number
MMIS Number
Current Symptoms
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Other
Current Symptoms and Issues
Upload Insurance Card and ID (front and back) and photo id
Additional information... including best date to contact.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Submit
Should be Empty: