Client Intake Form
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
Social Security Number
Client is a minor
*
Yes
No
Parent Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Primary Phone
*
Primary Phone Type
Home
Mobile
Work
Secondary Phone
Secondary Phone Type
Home
Mobile
Work
E-mail Address
*
example@example.com
Payment Information
Payment Method
*
Self Pay
Insurance
Medicaid
Insurance Company
*
Please tell us what company or Medicaid MCO your insurance is through.
Member ID
*
This number may also be called the Identification number or Policy number.
Group Number
(If applicable)
Insurance Policy Holder
Patient's Relationship to Policy Holder
*
Self
Spouse
Child
Other
Policy Holder Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Gender
*
Male
Female
Social Security Number
Consent Forms
Consent to Treatment & Privacy Practices
*
Fee Schedule & Billing Practices
*
By signing below, I certify that I am the patient, or the legal guardian or care-taker of said patient.
Upon submission, a copy of this form will be e-mailed to you for your records.
Name
*
Signature
*
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