INTAKE REQUEST FORM
readmission
svcID
prov code
Patient Age:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Who is completing this form:
First Name
Last Name
Their Relationship to Patient:
Requested Clinician:
None
Woman
Man
Psychiatrist
Psychologist
Social Worker/Counselor
Shin-Bey Chang, MD
John Bricker, LCPC
Mary Beth Curry, LCPC ACC
Kevin Graditor, LCSW-C
Florent Grain, LCPC
Janice Herron, PhD
Jennifer Howell, LCSW-C
Cynthia Keysor, PhD
Zeb Khan, MD
Malorie Marti, LCPC
Christie Tanner, PhD
Grace Thammasuvimol, MD
Winelis Rodríguez-Márquez, LCPC
Robert Vinson, LCPC
Patient Name:
*
First Name
Last Name
Preferred Name:
Patient D.O.B.:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender:
male
female
other
Pronoun:
he
she
they
Contact Name (since patient is a minor):
*
First Name
Last Name
Email Address:
*
Primary Phone:
*
home, work or cell:
home
work
cell
Alt. Phone #1:
home, work or cell:
home
work
cell
Alt. Phone #2:
home, work or cell:
home
work
cell
Preferred Method of Contact:
Please Select
email
phone
no preference
Home Address:
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Services Interested In:
Please Select
Individual Therapy
Couples Therapy
Family Therapy
Medicine Management
Neuropsychological Evaluation
Other
Are you a returning patient?
Please Select
yes
no
If yes, who did you see?
If yes, when were you seen?
Please Select
0 - 6 mos
6 mos - 1 year
1 - 3 years
3 - 5 years
5+ years
If no, who referred you?
Insurance Information
Insurance Name:
*
ID #:
Group #:
Policy Holder Information:
Name:
First Name
Last Name
D.O.B.:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
How Related to Patient:
Please briefly explain reason for seeking therapy
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