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
Home
Phone (cell)
Cell
Phone (Work)
Work
Phone (other)
Other
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)
Phone

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
Address (insurance)

Street Address

Street Address Line 2

CityState / Province

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

YesNo

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)*

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Name (print)*

First NameLast Name
Date*

MonthDayYear
Date

3. PRIOR COUNSELING
Have you been in counseling before?

YesNo

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.
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: