Intake form

Client's Name

First NameLast Name

E-mail

Preferred pronouns

Reason for Counseling

Therapist requested (if any)

Office location preference

Preferred days/times for appointments

Do you prefer in-office or telehealth?

Returning client:

Client's Date of Birth

MonthDayYear

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian's name

First NameLast Name

Relationship to Client

Parent/Guardian's Date of Birth

MonthDayYear

Parent/Guardian's name

First NameLast Name

Relationship to Client

Parent/Guardian's Date of Birth

MonthDayYear

Are you willing to go on a waitlist?

Do you have a Primary Care Physician?

If yes, please list the providers name, and their medical office

If you do have a Primary Care Physician, have you been seen in the past 12 months?

If required, do you want coordination of care with your PCP?

Will you be utilizing EAP benefits? (Employee Assistant Plan)

Upload copy of BOTH SIDES of insurance card

Upload a File

You may scan and upload a copy of BOTH SIDES of your insurance card, or complete the information below.

Name of insurance company

Insurance ID number

Insurance Group Number

Insurance phone number (on back of card, phone # for Provider Services, Mental Health Benefits or Customer Service)

Area CodePhone Number

Policy Owner's Name

First NameLast Name

Policy Owner's date of birth

MonthDayYear

Secondary Insurance (if applicable)

Upload copy of BOTH SIDES of insurance card

Upload a File

You may scan and upload a copy of BOTH SIDES of your insurance card, or enter the information below.

Name of Insurance Company

Insurance ID Number

Insurance Group Number

Insurance phone number (on back of card, # for Provider Services, Mental Health Benefits, or Customer Service)

Area CodePhone Number

Policy Owner's Name

Policy Owner's Date of Birth

MonthDayYear

Have you had any counseling and/or seen a Psychiatrist in the past 12 Months?

YesNo

Psychiatric Medications taken within the last 12 months

How did you hear about CPD?

Name of referral source

Thank you for your interest in receiving services at the Center for Psychological Development. Our office staff will be in touch within 3 to 5 business days to schedule an appointment with you.

The following information is for internal office use only.

Therapists in network:

DT:

AT:

Time and Date of Intake Appointment