New Client Intake Form

Please Note

We cannot answer calls about a potential client until we receive this intake form

Name of person filling out this form

Relationship to client

Date

Demographics

Client Name

Date of Birth

Age

Client Gender

Male Female Other

Other: (please specify)

Grade Level or Highest Degree:

School Name:

Client Street Address 1:

Address 2:

City:

State:

Zip:

Client Cell Phone # (if a legal adult):

Client Home Phone #:

Client Work Phone # (if applicable):

Client Email:

Family Information

Parent / Guardian (1) Name:

Relationship to Client:

Phone #:

Email:

Parent / Guardian (2) Name:

Relationship to Client:

Phone #:

Email:

Does one or both parent(s) have guardianship over the client?

Yes No

Medical Information

Primary Care Physician (PCP) Name:

PCP Phone #:

Psychiatrist Name:

Psychiatrist Phone #:

Other Provider Name:

Other Provider Phone #:

Specialty:

Payment for Services

Out of Pocket

Are you paying for services out-of-pocket (will not be billed to insurance)? (If yes, disregard insurance and county sections)

Yes

Medical Insurance Information

Insurance Company Name:

Member ID:

Group #:

Policyholder Name:

Policyholder DOB:

Policyholder Relationship to Client:

Policyholder Employer:

Policyholder Address (if different from client's):

City:

State:

Zip:

Insurance Company Phone #'s:

Behavioral Health Phone #:

Provider Phone #:

Pre-certification Phone #:

Insurance Company Claims Address:

City:

State:

Zip:

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.)

Use the link below to upload copy

Add file

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

County

Caseworker Name:

Caseworker Phone #:

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.

Reason for seeking services (current problems / challenges):

Client Current Diagnosis or Diagnoses:

If you were referred to Amigo Family Counseling, LLC, who referred you?

Business Name:

Phone #:

Specialty:

If you were not referred, how did you hear about us:

Insurance company's provider list Internet Search From a client or parent of an existing client Other

If other, please specify:

If applicable, who were you referred to see at Amigo Family Counseling, LLC?

If known, what services are you seeking at Amigo Family Counseling, LLC: (Select all that apply)

Group Respons•ability Social Therapy (RST) Program

Psychological Testing (for RST program)

Diagnostic Testing (to determine or rule out an Autism Spectrum Diagnosis)

Individual Psychotherapy

Family Psychotherapy

The Integrative Medicine Program

The Creative Social Arts Program / Acting Workshops

Other (specify below)

Other:

When are you available? (Select all that apply)

Morning

Afternoon

Evening

Have you called the office for any other reason?

Yes No

If yes, who did you speak to?

Date:

Your information will be encrypted.

New Client Intake Form

Please Note

Demographics

Family Information

Medical Information

Payment for Services

Out of Pocket

Medical Insurance Information

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

County Funding

Please Note

Amigo Family Counseling, LLC

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