C.A.E. Behavioral Health - Initial Intake Form

Client Intake Form

Please complete this intake form in its entirety to the best of your ability. You will be contacted by a CAE Team Ambassador within 24 hours of submission.
How Did you Hear About Us?*
If other, how did you hear about us?
CLIENT INFORMATION
Name*

PrefixFirst NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Best Time to Call

Hour Minutes

AM/PM Option
Email
example@example.com
DEMOGRAPHIC INFORMATION
Marital Status*
Are you an adult with dependent children?*
Race*
Ethnic Origin*
Primary Language*
Are you a Veteran?*
Highest Grade Completed*
Employment Status*
Place of Birth*

Street Address

Street Address Line 2

CityState

Zip Code
HOUSING INFORMATION
Housing*
Current living arrangements
Number of People in Household

List all Dependent Children Living within the Home

	Dependent Child's Name	Date of Birth	Name of School/Daycare	List Any Disabilities/Chronic Illnesses
1.
2.
3.
4.
5.

List Any Adult/Non-Dependent People Living Within the Home

Are there any inadequacies or safety concerns within the home? (Check all that apply)

Feel SafeUnaffordableOvercrowdedUtilities shut offCriminal ActivityPhysical ViolenceOther
HEALTH INFORMATION

Behavioral and Physical Health client information.
Mental Health
Have you ever had feelings or thoughts that you didn't want to live?*
Do you currently feel that you don't want to live?*
Substance Use
Do you have any current or prior history of substance use? *
If so, list substances used and when
Physical Health

List Any Diagnosed Health Issues or Concerns

Complete Insurance Information.

	Name of Insurance Company	Name of Subscriber (if applicable)	Group ID/Member Number
1.
2.

ADDITIONAL SERVICES
Additional Services Needed (Check all that apply):

Legal AssistanceSNAP ApplicationMental Health Support/CounselingTransportationClothingFoodChildcareSpiritual SupportDomestic ViolenceAdult EducationAddiction Support GroupOther
SIGNATURE
I certify that all the information I have given is true and accurate to the best of my knowledge and belief. I agree to provide financial and other verification that may be needed to receive services. I also acknowledge to having the right to refuse any services offered by Community Arts Experience, Inc. (CAE) or any of their designated health care and/or service provider.*

Clear
Whether digital or encrypted, the electronic signature is intended to authenticate this document and has the same force and effect as a manual signature.
HIPPA Notice of Privacy Practices Statement
Name of personal representative completing intake form for client, if applicable

First NameLast Name
Personal Representative Phone

Client Intake Form