Intake Form

May we contact you at this email address to discuss scheduling and coordinate potential services?

Preferred Clinician:

Has this individual or any other immediate family member ever been seen at our practice?

Previous patient’s name:

Previous clinician seen:

Spouse/Other Parent’s Name:

If you are a parent seeking treatment or evaluation for a child and are divorced or separated from the child’s other parent, please answer the following questions:

Do you have sole legal custody?
(Legal custody is not the same as Physical Custody. Sole legal custody means the parent legally has complete control to make decisions for the child.)

Yes

Do you believe the other parent will consent to treatment?

Yes

Is there currently, or do you anticipate a legal battle over custody, visitation, or anything related to the child?

Yes

Who, if anybody, referred you to our practice?

Do we have permission to thank the person who referred you?

Yes

Do you plan on using your health insurance to pay for our services?

Yes

What type of health insurance do you have?

Subscriber’s Name:

Subscriber’s Date of Birth:

Subscriber’s Social Security Number
(required for United Health Plans)

Insurance Identification Number:

Suffix #

Insurance telephone # for mental health benefits:

Insurance telephone # for medical benefits:

When does your health plan renew: Unsure

Employer or other entity where health plan is obtained

Is the health plan a union or employer self-funded or trust plan?

Yes

Unsure

Provide employer or plan contact name and telephone if available:

Name:

Phone #:

Do you have secondary insurance?

Yes

What type of health insurance do you have?

Subscriber’s Name:

Subscriber’s Date of Birth:

Subscriber’s Social Security Number
(required for United Health Plans)

Insurance Identification Number:

Suffix #

Insurance telephone # for mental health benefits:

When does your health plan renew: Unsure

Employer or other entity where health plan is obtained

Is the health plan a union or employer self-funded or trust plan?

Yes

Unsure

Provide employer or plan contact name and telephone if available:

Name:

Phone #:

Has the potential patient used any mental health insurance benefits this calendar year?

Yes

How many visits with a mental health clinician do you think you have used this year?

Has the potential patient ever been hospitalized for psychiatric reasons?

Yes

When was the last hospitalization?

Has the potential patient ever been hospitalized for substance abuse?

Yes

Briefly describe the nature of the problem you are seeking services for:

Are the services you are seeking related to an automobile accident?

Yes

Please provide: Insurance Carrier:

Address:

Insurance Adjuster Name (full name):

Policy Number:

Claim #:

Phone #:

Are the services you are seeking related to a workplace accident?

Yes

Are the services you are seeking related to any type of lawsuit, hearing or other legal process?

Yes

List all past and current medical diagnoses/problems of the potential patient:

List all current medications and dosage:

List the names and professions of any other professionals you have consulted about these problems:

What type of services are you seeking? Please check all that apply.

Unsure. Would like evaluation and recommendations for services.

Medication / Psychopharmacology

Individual Psychotherapy

Neuropsychological Evaluation

Psychological Evaluation

TMS

Telehealth: Would you be interested in seeing your clinician remotely using videoconferencing?

Yes

Are you (or your child if they are the patient) currently seeing a therapist?

Yes

How often is the therapist being seen?

weekly

every other week

monthly

less than momthly

Therapist name:

Therapist phone #:

If seeking medication, can the patient come between 10:00am-2:00pm on a monthly basis?

Yes

At which office would you prefer to receive services?