Step 1 of 4

25%

FOR OFFICE USE ONLY

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*

POTENTIAL CLIENT 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.

Client Name (Last, First, Middle)

Date of Birth

MM slash DD slash YYYY

Client's Preferred Name

Preferred Pronouns

Client's Gender

Male

Female

Non-binary

Client's Social Security Number

Best Phone Number

Client's Address

Street Address Address Line 2 City State ZIP Code

Second Parent/Guardian's Name (if applicable)

Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Relationship to Client

Type of Appointment Reminder

Text

Both

DBH Communication Email Address:

DBH Communication Cell Phone:

Is the client pregnant?

Yes

Number of children the client is financially responsible for

Name of the school the client attends

Is the client seeking treatment specifically related to your maternal mental health?

Yes

DEMOGRAPHICS

Source of Payment

Medicaid

Medicare

Commercial Insurance

Self Pay

Veteran's Administration

Worker's Compensation

Service Contract

Other

Other Source of Payment

Referral Source

Family/Friend

School System

Other Health Care Provider

Other Community Referral

Self

DCFS

Employer

Division of Workforce Services

Mental Health Provider

Substance Use Provider

Clergy

DSPD

Justice Referral

Client's Marital Status

Married

Divorced

Separated

Widowed

Never married/single

Client's Race (Primary)

White

Alaskan Native

Hawaiian/Pacific Islander

American Indian

Asian

Black/African America

Other Single Race

Two or More Races

Client's Ethnicity (Primary)

Cuban

Mexican

Puerto Rican

Not of Hispanic Origin

Other Hispanic

Unknown

Other

Other Ethnicity

Preferred Language (if other than English)

Client's Living Arrangement

24 Hour Residential

Foster Home (Adult or Child)

Institutional Setting

Jail

Private Residence/Independent

Homeless or Shelter

Private Residence/Dependent

Have you (client) been civilly committed?

Yes

Have you (client) ever or are you currently serving in the military?

Yes

Has the client been enrolled in school in the last 3 months?

Yes

Last grade client has completed in school

Client's Employment

Age 0-5

Disabled, Not Working

Employed Full-time 35+ hours

Unemployed/Not Seeking

Retired

Unemployed Seeking

Supported/Transitional Employment

Student

Employed Part-time -35 hours

Homemaker

Has the client previously had mental health treatment?

Yes

Has the client ever been hospitalized at the State Hospital?

Yes

Has the client ever been treated at Davis Behavioral Health?

Yes

Has the client ever taken any of the following medications below?

Yes

(Clozaril, Seroquil, Zyprexa, Risperdal, Geodon)

Client's Nicotine Use

Never Smoked/Vaped

Former Smoker/Vape

Current Someday Smoker

Current Everyday Smoker

Use Smokeless Tobacco

Age of First Use

HOUSEHOLD FINANCIAL INFORMATION

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.

Provide Financial Information

Client does not want to provide financial information.

Earnings/Wages

Workers Compensation

SSI

SSD

Social Security

Retirement

Food Stamps

Welfare Benefits

Alimony/Child

Other Income

Total Monthly Income

Are you insured?

Yes

INSURANCE INFORMATION

Primary Insurance Company Name

Insurance Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Primary Insurance Phone Number

Policy Holder Name

Primary Insurance Policy Holder Date of Birth

MM slash DD slash YYYY

Policy Number

Secondary Insurance Company Name

Insurance Address

Street Address Address Line 2 City State ZIP Code

Secondary Insurance Phone Number

Policy Holder Name

Secondary Insurance Policy Holder Date of Birth

MM slash DD slash YYYY

Policy Number

Photo of Insurance Card

Please upload a copy of both the front and back of the card in JPG or PNG format.

Drop files here or

Max. file size: 64 MB.

Signature

Client Name

Date

MM slash DD slash YYYY

Parent Name (For Minors)

FOR OFFICE USE ONLY

Client does not want to provide income informtaion

Therapy Copay $_________________________________

Medical Copay $_________________________________

BHN SSF PCG CASH ______________ visits at $_________________

Phone

This field is for validation purposes and should be left unchanged.

Intake Form

FOR OFFICE USE ONLY

POTENTIAL CLIENT INFORMATION

DEMOGRAPHICS

HOUSEHOLD FINANCIAL INFORMATION

INSURANCE INFORMATION

FOR OFFICE USE ONLY