Referral form
Self
Just Believe Life Enhancement Services
Intake form
Date:
*
-
Month
-
Day
Year
Date
Client Gender:
Please Select
Male
Female
Non-binary
Prefer not to say
Client Name:
First Name
Last Name
Client Social Security Number:
Social Security Number
Email:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Insurance Company*
Please Select
Ohio Medicaid
Molina
Cigna
Care Source
Humana
Medical Mutual
Ambetter
Tricare
Aetna
Buckeye
Are you currently
Employed
Unemployed
Student
Retired
Disabled
Referred By:
Insurance Company
Word of Mouth
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Internet Search
Other
Are you currently receiving mental health services? *
Yes
No
Not sure
Submit
Should be Empty: