New Patient Intake Form

Client Information

Today's date

Name of the person filling out this form

Your relationship to the patient

Preferred phone number

Email address

Name of patient (please list name exactly as it is listed with the insurance)

Patient's date of birth

Street Address

Apt/Ste

City

State

Zip

Medical History

Signature

Primary insurance subscriber's name (please list name exactly as it is listed on the insurance card)

Primary insurance subscriber's date of birth

Identification number on the front of the insurance card. (Please do not list the group number.)

Please enter the Toll Free number from the back of your insurance card so we can verify your Behavioral Health Benefit.

If you are seeking services for a child, please complete the following:

Married Single Divorced Widowed

If parents are separated, divorced or never married, do parents have joint legal custody?

Yes No

Mother's Full Name

Mother's Full Address

Mother's Home Phone

Mothers Cell Phone

Mothers's Work Phone

Father's Full Name

Father's Full Address

Father's Home Phone

Father's Cell Phone

Father's Work Phone

Please tell us in a few sentences what type of service you are interested in and why you are seeking services at this time:

Has the patient ever been hospitalized for anything related to mental health in the past?

Yes No

If yes, how long ago and in which in-patient treatment facility?

Is the patient currently using any non-prescribed substances?

Yes No

If yes, please name any and all substances being used.

Does the patient have a history of using non-prescription substances?

Yes No

If yes, please name any and all substances.

Is the patient seeing a psychiatrist outside of the Growth Opportunity Center?

Yes No

If yes, where and with whom?

Is the patient currently taking any prescribed medications for psychiatric related issues?

Yes No

Is the patient currently seeing a therapist outside of the Growth Opportunity Center?

Yes No

If yes, where and with whom?

Has the patient ever been treated at the Growth Opportunity Center in the past?

Yes No

If yes, with whom and how long ago?

Does the patient already have an appointment scheduled with a therapist at the Growth Opportunity Center?

Yes No

If yes, with whom and when?

Would you like to request a specific clinician? If so, visit our website www.gocenter.net and view our clinicians' profiles. Please note that not all clinicians are able to take new patients and not all clinicians accept all insurances. If your requested clinician is not available, we will make every attempt to match you with someone with similar training and approach to treatment.

What time of day would you be available to be seen? Please list days of the week and times (mornings, daytime, after school, evenings, or weekends).

Do you have any other preferences of which we should be aware?

Other important information:

Your information will be encrypted.

Growth Opportunity Center

Welcome to the Growth Opportunity Center. Please complete this intake form if you are seeking evaluation or therapy services. You will receive a phone call back from us within 12-24 hours (unless it is the weekend or holiday) to confirm receipt of this intake and to review business procedures. You should not use this form if you have a psychiatric emergency or crisis. In the event of an emergency, you should contact a psychiatric crisis center or go to the nearest emergency room. If you are having difficulty completing or submitting this form, please call our office during normal business hours Monday-Friday 9:00am-4:30pm at 215-947-8654 dial "5" for office. Thank you and we are looking forward to serving you.

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