Patient Intake Information

This information is for

Child Patient Adult Patient

Person completing form

Relationship to Patient

Patient Name

Patient Goes by

Date of Birth

Age

Gender

Grade in school

Home Address

City

State

Zip

Home Phone

Cell Phone

Work Phone

Email address

I give permission to send texts to and leave voicemails and messages on the numbers provided.

If unchecked, you will not receive appointment reminders or notification of online appointments.

Billing Options

File Insurance Self Pay

Payment is due at the time of service.

Any co-payment is due at the time of service.

Primary Insurance

Policy #

Group #

Effective Date

Insured's Name

Relationship to Patient

Insured's Date of Birth

Insured's Employer

Insured's Address

Insured's Phone #

I wish to enter Secondary Insurance Information

Secondary Insurance

Secondary Policy #

Secondary Group #

Secondary Effective Date

Secondary Insured's Name

Secondary Relationship to Patient

Secondary Insured's Date of Birth

Secondary Insured's Employer

Emergency Contact Name

Relationship to Patient

Emergency Contact Phone

Spouse/Significant Other's Name

Length of Relationship

Spouse's Occupation

Spouse's Employer

Click for additional children

Add a parent or guardian

Add Sibling

Patient's Occupation

Employer

Length of Employment

Educational Background

Highest Degree

Current School

Brief Statement of Concerns/Reasons for Being Seen

Primary Care Physician

Physician's Address and phone number

Physician Last Seen

Click to add medication

Medical Problems (current and past)

Add a prior treatment

Family History of Psychological Problems

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