Intake Form2

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

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

Email

Both

DBH Communication Email Address:

DBH Communication Cell Phone:

Is the client pregnant?

Yes

No

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

No

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

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

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

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 $_________________

FOR OFFICE USE ONLY

POTENTIAL CLIENT INFORMATION

DEMOGRAPHICS

HOUSEHOLD FINANCIAL INFORMATION

INSURANCE INFORMATION

FOR OFFICE USE ONLY