Therapy Intake Form

📋 Outpatient Therapy/Youth & Family Services Services Inquiry Form

Positive Alternatives & Outcomes
Client Information
Full Legal Name*

First NameLast Name
Parent/Guardian Name (if under 18)

First NameLast Name
Phone Number If Client is under 18, Provide Parent Phone #)*

Area CodePhone Number
Birth Date*

MonthDayYear
Gender*
E-mail (If Client is under 18, Provide Parent Email)*
How were you referred to our office?
Financial & Insurance Information
Primary Member ID #*
Clients Insurance card number
Primary Insurance Company name*
If other please complete below.
Secondary Insurance Company
Secondary Member ID #
Personal History
Is the client experiencing any of the following? (Please check all that apply)

AnxietyDepressionAngerAlcoholismStressDrug AddictionCommunication IssuesEating DisorderParenting IssuesAdoption IssuesAbandonment IssuesPost Traumatic Stress DisorderOtherTruancyIncarcerationCourt Action
List any major illnesses or hospitalizations:
Are you taking any medications or drugs?
Availability
Preferred Days/Times for Sessions

MondayTuesdayWednesdayThursdayFridaySaturdaySundayMorning (8am–12pm)Afternoon (12pm–4pm)Evening (4pm–7pm)
File Uploads
Upload Approved Funding Request (Required for DSS/CCSB Referrals)*

Browse Files

Cancelof
Attach front and back of insurance card (Required for Outpatient Clients*)

Browse Files
PDF, DOC, TIFF, JPEG Files only. Cancelof
Consent & Signature
I understand that submitting this form does not guarantee services. All information will be kept confidential in accordance with HIPAA. Please allow 24-28 business hours for a response.*

I agree
Digital Signature
Date

MonthDayYear
Date
Should be Empty:

📋 Outpatient Therapy/Youth & Family Services Services Inquiry Form

Client Information

Financial & Insurance Information

Personal History

Availability

File Uploads

Consent & Signature