F.A.M Healing Center - Service Request Forms

F.A.M Healing Center - Service Request Forms

Complete this intake packet to begin the process of becoming a client at F.A.M Healing Center.
Client Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employment Status
Income Range
Disability Status
Education Level
Preferred Language
Martial Status
Race

Other
Ethnicity
Veteran Status
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Upload Picture Identification Card

Cancelof
Type of counseling are you seeking?

Other
Which concern is the MOST important for us to address first?

Other
Why are you seeking counseling at this time?
What are your goals for counseling?
Referring Source
How will you pay for services?
Employee Assistance Program (EAP) Company
Magellan, Aetna, Cigna ect..
EAP Authorization Number
Court Referral Upload

Cancelof
Name Insurance Carrier
Member ID Number
Policy Holder
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Card Front Upload

Cancelof
Insurance Card Back Upload

Cancelof
How would you like services rendered?
In-Person Service Location

F.A.M Healing Center - Service Request Forms

Optional Faith-Based Support Services