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

Browse Files

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

Browse Files
PDF, DOC, TIFF, JPEG Files only. Cancelof
Consent & Signature
I agree
Digital Signature

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Date

MonthDayYear
Date
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📋 Outpatient Therapy/Youth & Family Services Services Inquiry Form