Interest Intake Form
Please complete this form for interest in services. Once this form is complete you will receive a follow up call to schedule your assessment for services. Talk to you soon!
Clients Name
First Name
Last Name
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Client Phone Number
Please enter a valid phone number.
Social Security # For Insurance Verification
Guardian's Name (if client is minor)
First Name
Last Name
Guardian's Name (if client is minor) Phone Number
Please enter a valid phone number.
Clients Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Relationship
Emergency Contact Phone Number
Clients Insurance Carrier
Insurance Name
Group Number
MMIS Number
Current Symptoms
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity
Anxiety attacks
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Excessive guilt
Increased irritability
Fatigue
Crying spells
Decreased libido
Other
Current Symptoms and Issues
Upload Insurance Card and ID
Additional information... including best date to contact.
Date
-
Month
-
Day
Year
Date
Signature
Guardian Signature (if under age 18)
Submit
Submit
Should be Empty: