Therapy Intake Form

📋 Outpatient Therapy Services Inquiry Form

Positive Alternatives & Outcomes
Personal Information
Full Legal Name*

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

First NameLast Name
Phone Number*

Area CodePhone Number
Birth Date*

MonthDayYear
Gender*
E-mail*
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
Are you experiencing any of the following? (Please check all that apply)

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

MondayTuesdayWednesdayThursdayFridaySaturdaySundayMorning (8am–12pm)Afternoon (12pm–4pm)Evening (4pm–7pm)
File Uploads
Upload a copy of your government-issued ID:

Browse Files
PDF, DOC, TIFF, JPEG Files only. Cancelof
Attach front and back of insurance card

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.*

I agree
Digital Signature

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📋 Outpatient Therapy Services Inquiry Form