New Client Intake Form

Amigo Family Counseling, LLC

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Demographics

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    Family Information

    Medical Information

    Payment for Services

    Out of Pocket

    Medical Insurance Information

    Insurance Company Phone #'s:

    *If you would like to provide a copy of your insurance card*

    (Please Note: This link is for insurance card copies only. Please do not attach any other forms of documentation.)

      Please upload a file

      Note: If you have UnitedHealthCare/Optum insurance, please be aware that they will not release benefits information to our office without prior verbal consent from the primary insurance holder.

      County Funding

      Note: If you are funded by Franklin County, scheduling will not occur until after we receive an authorization from your caseworker to cover services. Please alert your caseworker about seeking services and inquire about a pre-authorization.

      *Please Note*
      Follow up phone calls for intakes are generally made Tuesday - Thursday, 6:30pm - 9:00pm. The Phone # associated with follow up calls is (614) 310-1234. As some of our staff are making phone calls outside of normal office hours the Caller ID may read "unknown" or "private."

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