New Patient Intake Form

Information

Today's date

Your name

Phone number

Email address

Are you interested in services for yourself?

For myself

For someone else

If someone else, please enter their name and relationship to you.

Date of Birth of patient

Street Address

Apt/Ste

City

State

Zip

Insurance Information

Do you currently have health insurance?

Yes No

Provide insurance information if not listed above. (Please note, GOC does not accept any State Medicaid plans.)

Please upload an image of your card so we can verify your benefit coverage.

If you have difficulty uploading your card, please provide your ID#.

Services

What service are you interested in receiving?

Therapy

Psychiatry (Medication Management)

Couples/Family Therapy

Psychological Assessment

Group Therapy

More than one service

Please tell us in a few sentences why you are seeking services at this time. Include any difficulties or challenges.

Have you ever received services with GOC in the past?

Yes No

Please indicate any preferences or requests to consider?

In the last several weeks, have you thought about or acted to harm yourself or someone else? Please explain.

Are you receiving behavioral health services with any provider currently? If so, please provide details.

Are you currently prescribed medication for mental health? Please provide information.

Is there any other information that is important for us to know?

What is your availability for services? For example, daytime, after school, evenings, or weekends. Please be aware that you will likely be matched quicker if you indicate a wide availability of time options.

What is the best time for a call back?

Your information will be encrypted.

Welcome to Growth Opportunity Center!

Please complete this intake form if you are seeking services. You will receive a phone call back from us within within a few days to confirm receipt of this intake, to further discuss how we can help, and to review procedures. Please do not use this form for crisis or emergency. It is not monitored outside of regular business hours. In the event of an emergency, you should contact 911, text or call 988, or go to the nearest Emergency Department. If you would like to speak with staff, please call our office during normal business hours Monday-Friday 8:30am-4:30pm at 215-947-8654, option 1. Thank you! We are here to help!.

215-947-8654
928 Jaymor Road B-150 , Southampton, PA, 18966