Today's Date:
*
/
Month
/
Day
Year
Date
Client's Full Name:
*
Client's Date of Birth:
*
/
Month
/
Day
Year
Date
Phone Number:
*
Email
example@example.com
SSN #
###-##-####
Gender
*
Male
Female
Transgender
Other
Ethnicity
African American
White
Hispanic or Latino
Other
Is the client over 18 y/o:
*
YES
NO
Emergency Contact Name:
Emergency Contact Phone Number:
Emergency Contact Relationship
Client's Address:
Street Address
*
City,State,Zipcode:
*
If Patient is a Child Please Enter Parent/Guardian Name:
*
If not applicable enter N/A
Parent/Guardian Date of Birth:
/
Month
/
Day
Year
Date
Parent Guardian Phone number #:
Parent/Guardian Address,City,State,Zipcode:
Reason(s) for Referral (CHECK ALL THAT APPLY):
*
Depression/Anxiety
Post-partum Depression/Anxiety
Racial Related Trauma
Anger Management
PTSD
Behavioral Issues/ School Problems
Substance Abuse
Weight/Obesity
Medical Related Depression/Anxiety
Suicidal/Homicidal Ideations
Family Conflict
Grief/Loss
Infertility
MEDICATION MANAGEMENT
MEDICATION EVALUATION
Other
If Other is Selected Briefly Explain:
Current Medications :
Insurance/Billing Information:
Self-Pay
*
YES
NO
Insurance:
*
YES
NO
Medical Assistance:
*
YES
NO
Insurance Name:
*
If question is not applicable enter N/A
Insurance Policy Number:
*
If question is not applicable enter N/A
Insurance Group Number:
*
If question is not applicable enter N/A
Policy Holder Name and Date of Birth:
*
Medical Assistance Number:
*
If question is not applicable enter N/A
Are you utilizing EAP (Employee Assistance Program) benefits?
*
YES
NO
If Yes What EAP Benefits will you be using:
*
Compsych EAP
Aetna EAP
Wellspring EAP
Cigna EAP
N/A
Are you in need of assistance with a work or a school claim or leave ?
Yes
No
Attach PICTURE of Front and Back of Insurance Card & any additional information:
Browse Files
Cancel
of
Who Referred You / How did You hear about us? (Ex. Self, Insurance Company, Job...)
*
Submit
Should be Empty: