Child Intake Evaluation

Client Intake Evaluation
Please fill out the document below and click "Submit" when complete.
1. IDENTIFYING INFORMATION
Client's name*

First NameLast Name
Partner's name (if being seen as a couple)

First NameLast Name
Today's date

MonthDayYear
Date
Referred by
Gender
How do you identify?
Age
Birth date*

MonthDayYear
Date
Marital status
Employer
Email address
example@example.com
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
HomeFormat: (000) 000-0000.
Phone (cell)
CellFormat: (000) 000-0000.
Phone (Work)
WorkFormat: (000) 000-0000.
Phone (other)
OtherFormat: (000) 000-0000.
Reminder call*
Preferred number
Reminder (type)
Preferred contact type
Education
Self
Education (partner)
Partner
Occupation
Self
Occupation (partner)
Partner
Emergency contact

First NameLast Name
Emergency contact (phone)
PhoneFormat: (000) 000-0000.

Insurance Information
Name of subscriber

First NameLast Name
Subscriber relationship
Relationship of client to subscriber
Date of birth

MonthDayYear
Employer
Address (subscriber)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance company
Phone
Format: (000) 000-0000.
Address (insurance)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Identification number
Group number
Do you have secondary insurance?

YesNo
- Name of subscriber
  
  First NameLast Name
- Subscriber relationship
  Relationship to subscriber
- Date of birth
  
  MonthDayYear
- Employer
- Address (subscriber)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Secondary insurance
- Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Address (insurance)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Identification number
- Group number

Patient or Authorized Person's Signature
I authorize the release of any medical or other information necessary to process a claim. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to provider of services.
Signature (Insured)*
Name (print)*

First NameLast Name
Date*

MonthDayYear
Date

3. PRIOR COUNSELING
Have you been in counseling before?

YesNo
- Who did you see?
  
  First NameLast Name
- Dates
  
  MonthDayYear
  From
- Dates
  
  MonthDayYear
  To
- Describe what happened
  
  0/50
- Did you receive counseling prior to this?
  
  YesNo
- Who did you see?
  
  First NameLast Name
- Dates
  
  MonthDayYear
  From
- Dates
  
  MonthDayYear
  To
- Describe what happened
  
  0/50

5. MEDICAL INFORMATION
Have you seen a doctor in the last year?

YesNo
Why have you seen a doctor?

0/50
Doctor name

First NameLast Name
Phone (doctor)
Please enter a valid phone number.Format: (000) 000-0000.
Are you taking any medications (prescription or over-the-counter)?

YesNo
Please list any medications you are taking

0/50
Do you have any allergies?

YesNo
Please describe any allergy problems you may have

0/50
Should be Empty: