Start Wellness Intake Form

Intake Form
Client Name:
DOB:

MonthDayYear
Today's Date:

MonthDayYear
SECTION 1 - IDENTIFYING INFORMATION
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City/State/Zip:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone:
Format: (000) 000-0000.
Email:
SSN (if required for insurance):
xxx-xx-xxxx
Primary Insurance:
Policy#:
Secondary Insurance:
SECTION 2 - REFERRAL CLARITY
Who is receiving services?
Parent/Guardian (if applicable):
SECTION 3 - PRESENTING PROBLEM
Primary Reason for Seeking Services:
Duration of Concern:
Recent Changes:
Previous Treatment?
If yes:
SECTION 4 - MEDICAL NECESSITY SCREEN
Has client experienced:
Describe severity/frequency:
SECTION 5 - FUNCTIONAL IMPAIRMENT
Does this condition interfere with:
Explain:
SECTION 6 - CURRENT SUPPORTS
Primary Care Physician:
Psychiatrist:
Current Medication:
Other Providers
SECTION 7 - SAFETY
Current safety concerns?
If yes:
SECTION 8 - CONSENTS
Below are brief explanations for clarity:
1. Consent for Treatment

Explanation: This allows START Wellness to provide mental health and/or substance use services. Services cannot begin without this consent.
Initials:
2. Financial Authorization

Explanation: This allows START Wellness to bill Medicaid or insurance for services provided and communicate with billing entities as required
Initials:
3. Permission to Contact

Explanation: This allows START Wellness to contact you via phone, text, or email regarding appointments, scheduling, and care coordination.
Initials:
4. Permission to Leave Voicemail

Explanation: This allows START Wellness to leave messages related to services.
Initials:
5. Privacy & Client Rights Acknowledgment

Explanation: Confirms you received and understand your HIPAA privacy rights and grievance procedures.
Initials:
Signature (Client/Guardian
Date:

MonthDayYear
Staff Completing Intake:
Should be Empty:

Intake Form

SECTION 1 - IDENTIFYING INFORMATION

SECTION 2 - REFERRAL CLARITY

SECTION 3 - PRESENTING PROBLEM

SECTION 4 - MEDICAL NECESSITY SCREEN

SECTION 5 - FUNCTIONAL IMPAIRMENT

SECTION 6 - CURRENT SUPPORTS

SECTION 7 - SAFETY

SECTION 8 - CONSENTS