Intake

Resources

Payments + Insurance

Intake Form

Services Requested

If you chose other, please specify

First Name

Last Name

Intake Date

DAte Of Birth

Male / Female

Ethnicity

Record #

Social Security #

Insurance #/ Payee

Address

County

Member or Parent/Guardian Name/ Phone #

Legal Guardian

Guardianship Paperwork Needed?

School Grade (if applicable)

DJJ involvement (if applicable)

Primary Care Provider / PCP Phone #

PCP address

Pharmacy

Allergies

Current Medications

History of previous Counseling?

Primary Therapist

Current Diagnosis (If known)

Emergency Contact (Primary)

Phone # (Primary)

Relationship to member (Primary)

Emergency Contact (Secondary)

Phone # (Secondary)

Relationship to member (Secondary)

Presenting Problem

Primary Email

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