BCS Intake

BCS Intake
Date

MonthDayYear
Date
Name*

First NameLast Name
Gender*
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Mobile Phone Number*

Area CodePhone Number
Permission to Text*

YesNo
Home Phone Number

Area CodePhone Number
Who referred you or how did you find us?*
Employer/School*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Emergency Contact Phone Number

Area CodePhone Number
List Current Medications
Prescribing Psychiatrist
Reason for seeking counseling*
Most recent counseling experience
Appointments: If you need to miss an appointment, please cancel with your counselor as soon as possible. Cancellations made less than twenty-four hours before a scheduled appointment will be charged directly to you at our full fee.
Fees: Payment is required at the time of service. We charge an additional $35.00 for any returned checks. Financial responsibility rests with the client regardless of any insurance coverage or third party payor.
Should be Empty: