Isoke Method New Client Intake (HIPAA)
HIPAA-compliant new client intake form. Please complete all required fields and upload both sides of your insurance card. Attach the original DOCX for reference.
Patient Information
First Name
*
Last Name
*
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Street Address
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
ZIP Code
*
Preferred Contact Method
Phone
Text
Email
Insurance Information
Primary Insurance Company
*
Member ID
*
Group Number
Policy Holder Name
*
First Name
Middle Name
Last Name
Policy Holder Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Policy Holder
*
Self
Spouse
Parent
Other
Secondary Insurance?
*
Yes
No
Secondary Insurance - Primary Insurance Company
Secondary Insurance - Member ID
Secondary Insurance - Group Number
Secondary Insurance - Policy Holder Name
First Name
Middle Name
Last Name
Secondary Insurance - Policy Holder Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Secondary Insurance - Relationship to Policy Holder
Self
Spouse
Parent
Other
Insurance Card Uploads
Upload Front of Insurance Card
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Back of Insurance Card
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Reason for Visit and Clinical History
What brings you to Isoke Method today?
*
Symptoms
Anxiety
Depression
ADHD
OCD
PTSD/Trauma
Mood swings
Panic attacks
Sleep problems
Relationship concerns
Stress
Other
Current therapist?
Yes
No
Therapist name
Current psychiatric provider?
Yes
No
Provider name
Primary care provider
Current psychiatric medications
What are your goals for treatment?
What would success look like over the next 6–12 months?
Appointment and Service Preferences
Appointment Preference
*
Telehealth
In Person
Either
Preferred Days
Monday
Tuesday
Wednesday
Thursday
Preferred Time
Morning
Afternoon
Evening
Services Requested
*
Medication Management
Medication + Therapy
Diagnostic Evaluation
Second Opinion
Are you seeking ongoing psychiatric care?
*
Yes
No
Active legal/disability/FMLA/workers' compensation/custody matters requiring psychiatric documentation?
*
Yes
No
Are you currently having thoughts of harming yourself?
*
Yes
No
Emergency Contact and Acknowledgements
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Acknowledgements
*
Completing this form does not establish a provider–patient relationship.
Insurance verification is not a guarantee of payment.
I understand I am responsible for deductibles, copays, coinsurance, and non-covered services.
I authorize Isoke Method to contact me.
Submit
Should be Empty: