Intake Form

Intake Form

Please complete this form as thoroughly as you can. Our Intake staff will review your submission and contact you with next steps.
Your Name*

First NameLast Name
Are you interested in services for yourself or someone else?*

For myselfFor someone else
Date of Birth for person interested in services*

MonthDayYear
Date
If completing this form for someone else, enter their name and your relationship to the client.
Name and relationship
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Insurance Information

Please share your insurance information so we can verify your coverage.
Do you currently have medical insurance?*

YesNo
Please be advised that Growth Opportunity Center does not accept any State Medicaid plans. If you do not have insurance, our Intake staff can discuss options with you.
Select your insurance coverage type

AetnaAllied Trades Assistance ProgramAmeriHealthCignaHighmark BCBSHumanaIndependence AdministratorsKeystone Health Plan East (Independence)MedicarePersonal Choice (Independence)Quest Behavioral HealthUnited Health Care/OptumOther Blue Cross/Blue Shield planOther plan not listed
Insurance type if not listed above.
Enter your policy member ID#
Member ID
Please upload an image of your insurance card(s) below.
Do you have any Secondary coverage? If so, please enter the insurance carrier and policy number.
Insurance carrier and policy number of secondary coverage
Services

Please provide the information below to help us understand your current needs and services you’re seeking.
Indicate what service(s) you are interested in receiving.*

TherapyPsychiatry (Medication Management)Couples or Family TherapyPsychological AssessmentGroup
Tell us in a few sentences why you are seeking services at this time. Include any recent difficulties, changes, or concerns that may help us understand your needs better.*
Have you ever received services with Growth Opportunity Center in the past?*

YesNo
How did you hear about us?*
In the past several weeks, have you thought about or acted to harm yourself or someone else? Please explain.*
Are you currently receiving behavioral health services with any other provider? If so, please provide details.*
Are you currently prescribed medication for mental health? Please provide information, including the name of the prescriber.*
Is there any other information that is important for us to know?
Indicate your availability for services. Please be aware that you will likely be matched quicker if you indicate a wide availability of time options. Check all that apply*

Available anytimeDaytimeLate afternoon (3:00-5:00pm)Evenings only (after 5:00pm)
Do you have a preference for provider?
We will do out best to match your request, though factors like provider availability and credentialing may affect options. Intake staff will review this with you
Your best time for a call back?*
Calls will be returned during regular business hours Monday-Friday. If you are in need of immediate support call or text 988. If you are experiencing crisis, call 911 or go to your nearest Emergency Room.
Should be Empty:

Intake Form

Insurance Information

Services