Clone of Longwood Psychological Center Intake Form

Child Name:

Child's Preferred Name:

Gender:

Date of Birth:

Date

Billing Address:

City

State:

Zipcode:

Parent 1 Name:

Parent 1 Cell:

Parent 2 Name/Cell:

Parent Email:

example@example.com

Primary Insurance Company:

If you do not have insurance, type NA for all insurance questions.

Policy/Member/ID Number:

Group Number:

Primary Insurance Holder Name:

Primary Insurance Holder Date of Birth:

Primary's Relation to Patient:

Type Self if the primary is the patient.

Secondary Insurance company:

Leave Blank if you do not have secondary insurance coverage

Secondary Insurance Contract Number:

Secondary Insurance Holder Name:

Secondary Insurance Holder's Date of Birth:

Referred by:

Requested Therapist:

Please describe in detail why you are seeking services:

This information will be released to your therapist.

If there is any type of custody agreement, please briefly explain below:

Please either bring in or email us a copy of the custody agreement for the child's records.

Are you currently or will you be involved in legal proceedings?

Other