Clinical Intake Form

Client Intake Form

Clinical Intake Form

Please complete this form to help us provide you with the best possible care. All information is confidential and protected by HIPAA.

First name

Last name

Date of birth

Month

Day

Year

Email address

Phone number

Home address

Gender

Male

Female

Non-binary

Prefer not to answer

Emergency contact name

Emergency contact phone

Relationship to emergency contact

Last 4 Digits of Social Security

Treatment Option

Type of Treatment

MENTAL HEALTH - Individual Therapy

MENTAL HEALTH - Group Therapy

SUBSTANCE ABUSE - Individual Therapy

SUBSTANCE ABUSE - Group Therapy

What is the desired help client is looking for?

Have you received mental health treatment before?

Previous mental health treatment details

Previous Substance Use details - Drug of choice, Last time used,

Are you currently taking any medications?

Current medications

Insurance Information

Insurance company name

Policy holder name

Policy number

Group number

Relationship to policy holder

Self

Spouse

Child

Other

Insurance effective date

Month

Day

Year

I authorize the release of medical information necessary to process insurance claims and I assign benefits to the provider.

I have read and understand the Notice of Privacy Practices and consent to treatment.

Patient signature

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