Intake Form

Intake Form

Please complete and we will match you to services
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Marital Status
Email
example@example.com
Employment
Type of Insurance
Referral Name

First NameLast Name
Home Phone
Cell Phone
Preferred Method of Contact

E-mailHome PhoneCell Phone
Emergency Contact Information
Name

First NameLast Name
Phone Number
Relationship
Insurance Information
Name of Insurer

First NameLast Name
Insurer Phone Number
Subscriber Name

First NameLast Name
Subscriber Date of Birth

MonthDayYear
Date
Subscriber Relationship to Patient
Group Number
Policy Number
Medical History
Please check all the apply

NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
Do you use tobacco?

NoDailyWeeklyLessFormer User
Do you use alcohol?

NoDailyWeeklyLessFormer User
Caffeine use?

NoDailyWeeklyLessFormer User
Have you been convicted of drug related charges?

YesNo
Please explain the circumstances
Are you currently taking prescription medication?

YesNo
Prescribing Doctor's Name

First NameLast Name
Prescribing Doctor's Phone
Have you had any surgeries in the past 5 years?

YesNo
Please specify:
Family history

AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
Mental Health History
Why you are seeking treatment?
What do you expect from this counselling?
Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?

YesNo
Therapist Name

First NameLast Name
Reason for seeking help
Average hours of sleep per night
Please describe any other experiences you have had problems with
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.

🛡️ HIPAA Privacy & Confidentiality Acknowledgment
Notice of Privacy Practices (HIPAA):

By completing this form, you acknowledge that the information provided may include protected health information (PHI). In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and Illinois state law, Mental Health Meets Hip-Hop is committed to maintaining the privacy and confidentiality of all personal and health-related information you share.

Your information will only be used or disclosed:

For the purpose of coordinating mental health referral services
With your written consent
As required by law (e.g., in cases of danger to self or others, child abuse, or court order)
All records are stored securely, and your data will not be shared with third parties without your authorization.

☑️ By signing or submitting this form, you consent to the collection, storage, and use of your information in accordance with HIPAA regulations and Illinois Mental Health and Developmental Disabilities Confidentiality Act (MHDDCA).
Date

MonthDayYear
Date
Signature

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Intake Form

Emergency Contact Information

Insurance Information

Medical History

Mental Health History