CareAngel Mental Health and Wellness Intake Form

Welcome to CareAngel Mental Health & Wellness

To provide you with the highest quality of care, we kindly ask that you complete this Patient Demographic and Insurance Intake Form. The information you provide helps us better understand your background, verify insurance coverage, and ensure our services are tailored to your unique needs.

All information is kept strictly confidential and used solely for clinical and administrative purposes in accordance with HIPAA regulations.

Thank you for taking the time to complete this form, we’re honored to support your journey toward healing and wellness.

First Name

MI

Last Name

DOB

SSN

Gender

Marital Status

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

Email

example@example.com

Primary Care Physician Name

Primary Care Physician Number

Emergency Contact Phone

Patient Detail (Under age 18 only)

ParentGuardian Name

ParentGuardian Cell

ParentGuardian Address

ParentGuardian Email

example@example.com

Please share your insurance information and upload a front and back copy of your insurance card.

Primary Insurance Name

ID

Grp

Member Name

Member Number

Secondary Insurance Name

ID#

Group #

Policy Holder Name

Policy Holder Address

Relationship with Policy Holder

Please upload the following: (1) front and back identification card (2) front and back copy of your insurance card

Patient Signature

I hereby authorize the release of my medical information for processing any claims, and I authorize payment of medical benefits to the physician for services provided.

Date