Intake Form

Emergency Assistance

If this is an emergency, call:

Office: (870) 237-1329
After Hours: (870) 230-0596
988 or 911

Client Information

First name

Last name

Parent/Guardian name if applicable

Home Address

Phone number

Email address

Date of birth

Insurance Company Name

Insurance Member ID #

Primary Care Physican (PCP referrals are required for Medicaid Patients)

Medical History

Have you been treated for mental health issues in the last 12 months?

Yes No

If yes, please describe the reason for your visit

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Do you have any allergies to medications?

Emergency Contact Information

Add another emergency contact

By E-signing this form I consent to allow A Time for Peace Inc. to contact me regarding scheduling an appointment and I consent to receive mental health treatment either in office or via tele-health. I consent to allow A Time for Peace Inc. to bill my insurance on my behalf for compensation for claims and I understand that co pays, deductibles or self pay balances are due at time of services. Self pay rates are $150 per hour but discounts are available based on household size and income. A copy of a financial aid application can be request from office staff. I understand there is a $25.00 no show fee for all missed therapy appointments and a $50.00 no show fee for missed medication/eval appointments. All or part of the no show fee may be required prior to scheduling a follow up appointment. I understand that A Time for Peace Inc. follows the HIPAA law and may only disclose PHI with my written consent or when permitted/required by law. More detailed consent forms and a copy of the privacy policies can be found in my patient portal.

Patient E-Signature

Date

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