Urban Healthy Minds – Client Registration and Consent

Urban Healthy Minds – Client Registration and Consent

Intake & Consent Form - Practice Information: Phone #: (702)-661-7436 Email: Info@urbanhealthyminds.com
CLIENT NAME:*

First NameLast Name
GENDER*
Gender: Male/Female/Other: Nonbinary/Other
Age:*
Date of Birth (MM/DD/YYYY): *
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Today's Date*

MonthDayYear
Date
Parent/Guardian Information (If Applicable) Name of Parent/Guardian:

First NameLast Name
Emergency Contact Telephone Number:
Relationship to Client:
EMERGENCY CONTACT
Emergency Contact Name:

First NameLast Name
Appointment Communication Preferences:
Would you like to receive appointment reminders? If yes, please indicate Preferred method(s) of communication Please indicate all applicable methods: Text Message, Telephone Call, or Email
Preferred time to contact you:
Healthcare Providers

Please list the names and specialties of any healthcare providers currently involved in your treatment (e.g., primary care physicians, specialists, therapists):
Name:  First Name   Last Name     SPECIALITY
Name:  First Name   Last Name SPECIALITY:

Are you currently taking any prescribed medication?    YES     NO
If yes, please specify the medication(s) and dosage(s):
    Medication Name:        Dosage

Do you have a Primary Care Physician?    YES      NO  If yes, Name of Physician :First Name   Last Name
INSURANCE INFORMATION

PATIENT AND/OR GUARDIAN
Legal Custody Status: Yes/No
Legal Custody Status: If yes, please attach relevant custody documentation.

Cancelof
Signature of Client (or Parent/Guardian):

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Date

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Date
Consent and Authorization By signing below, I affirm that I have thoroughly reviewed and understood the information provided in this form. I hereby grant my consent for Urban Healthy Minds and its authorized representatives to utilize the above information for registration purposes, care coordination, and essential communication regarding my services. I acknowledge that all personal information will be managed with the utmost confidentiality in compliance with applicable privacy protection laws.

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Urban Healthy Minds – Client Registration and Consent

Healthcare Providers

INSURANCE INFORMATION