New Client Intake Form

Amigo Family Counseling, LLC

Please correct the errors described below.

Demographics

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.

    Your information will be encrypted.

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