F.A.M Healing Center - Intake Forms

F.A.M Healing Center - Intake Forms

Complete this intake packet to get started with your behavioral health services.
Client Name

First NameLast Name
Today's Date

MonthDayYear
Date
Date of Birth

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

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How will you pay for services?
EAP Referral
EAP MAT #
Referring Source
Court Referral Upload

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Type of counseling are you seeking?

Other
Presenting Concerns

Other
Are you currently experiencing any of the following?
If you are in immediate danger, call 911 or go the the nearest ER
How would you like services rendered?
In-Person Service Location
Name Insurance Carrier
Insurance Card Front Upload

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Insurance Card Back Upload

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Policy Holder
Policy Holder Name

First NameLast Name
Policy Holder Date of Birth

MonthDayYear
Date

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