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Date of First Contact: ________________ Date of Scheduled Appointment: ___________________ Date offered: ____________________
Caller: __________________________ Relationship to Caller: ______________________ Clinician: __________________
If completing this form for your child (under 18) please provide child's information*
*Please be aware that the name and gender you list below must also be listed on insurance and billing documents.
If your preferred name, pronouns, or gender identity differ from what is listed, please note in sections below.
If you are uninsured or seeking substance use services, please complete the information below to qualify for a discounted rate.
If the client is a minor, please include the parent's financial information.
Client does not want to provide income informtaion
BHN SSF PCG CASH ______________ visits at $_________________