Networks, Inc. Intake Form

Client/ Patient Name *

First Name Last Name

Gender *

Date Of Birth *

Age *

Address *

Social Security Number

Primary Phone Number *

- Area Code Phone Number

Primary Phone Number Type *

Home Work Cell

OK To Leave A Message On Primary Phone? *

Yes No

Secondary Phone Number

- Area Code Phone Number

Secondary Phone Number Type

Home Work Cell

OK To Leave A Message On Secondary Phone?

Yes No

Email Address *

Place Of Employment *

Referral Source

Parent/ Guardian Name (if under 18)

Legal Guardian?

Yes No

Parent/ Guardian Address

Parent/ Guardian Phone Number

- Area Code Phone Number

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

- Area Code Phone Number

Type of Therapy Requested *

Individual Couple Family Group Medication Evaluation

Preferred Day/ Time For Appointments

Current Medications

Prescriber Name and Phone Number

Primary Care Provider Name and Phone Number

Primary Insurance Name *

Primary Insurance ID *

Primary Insurance Policy Holder Name, DOB, and Relationship to Client (if different)

Secondary Insurance Name

Secondary Insurance ID

Secondary Insurance Policy Holder Name, DOB, and Relationship to Client (if different)

Reason(s) For Seeking Therapy At This Time *