0 - Treatment Inquiry Form

Treatment Inquiry Form

Looking to see a therapist at Networks? Completing this secure form is the first step and will help us connect you with the right provider.
Client/ Patient Name *

First Name Last Name
Referral Source
Self if not referred by another provider.
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email
example@example.com
How can we leave/send you a message?

Phone Text Email
How would you prefer we contact you?

Phone Email
Primary Phone Number *

Area Code Phone Number
Primary Phone Type *

Home Work Cell
Secondary Phone Number

Area Code Phone Number
Secondary Phone Type

Home Work Cell
OK to leave phone message or text? *

Yes No
OK to send an email? *

Yes No
Social Security Number
Date of Birth *
Age *
Gender *
Place Of Employment *
Parent/ Guardian Name (if under 18)
Leave blank if not applicable.
Legal Guardian?

Yes No
Parent/ Guardian Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Phone Number

Area Code Phone Number
Current Medications
Leave blank if none.
Prescriber Name and Phone Number
Primary Care Provider Name
Primary Care Provider Phone Number
Primary Insurance *
Name of insurance company.
Primary Insurance ID *
Primary Insurance Policy Holder Name, DOB, and Relationship to Client (if different)
Secondary Insurance
Name of company. Leave blank if none.
Secondary Insurance ID
Secondary Insurance Policy Holder Name, DOB, and Relationship to Client (if different)
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone Number.
Preferred Day/ Time for Appointments
Type of Therapy Requested *

Individual Couple Family Group Medication Evaluation
Specific provider requested?
Reason(s) For Seeking Therapy At This Time *
Should be Empty: