New Client Intake Form

Welcome to

First Name

Middle Initial

Last Name

Recorded Gender for Health Insurance

Male Female

Date Of Birth

Phone Number

Address

City

State

Zip Code

Email address

Responsible Party (if minor)

Subscriber’s Name

Subscriber’s Date of Birth

Subscriber ID/Member #

Please provide copy of front and back of insurance cards to prevent delays.

Add file

Please upload a file

Are you currently on any psychiatric medications? If yes. What are they?

What are the general symptoms you are experiencing?

Any recent hospitalizations?

Yes No

Name of facility

Discharge Date

How did you hear about Ferncroft Behavioral Health?

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