Living Bread Intake Form

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Today's Date

Patient Name

Are you the patient?

Yes No

Your Name

Your Telephone Number

Service Requested

Mental Health Counseling

There is currently a waiting list for counseling. Select this box if you would like to be added to the waiting list.

Nutritional Counseling

Were you referred to Living Bread?

Yes No

Please provide the name of the person who referred you to us today.

Please provide the phone number of the person who referred you.

How did you hear about us?

Date of Birth

Phone Number

Email address

What is the reason for your visit to Living Bread or what is your presenting problem?

Are you being referred to us?

Yes No

What is the name of your referring physician or counselor?

Are you interested in financial assistance for your visits? Please note that all financial assistance is currently allocated. If you would be interested in joining the wait list, please select Yes to this option.

Yes No

We offer assistance based on a sliding scale. A separate form, including documentation, will be required.

Do you have Blue Cross Blue Shield (BCBS) Insurance?

Yes No

Currently, we can only file BCBS insurance for mental health counseling; however, we can provide receipts for you to file your own insurance.

Is there anything else that might be helpful for us to know at this point? Use this space to share that information with us.

This form will automatically be submitted to the Intake Coordinator at info@livingbreadgreenville.org. If you have any questions once this form is submitted, you can email them to us at that address.

Thank you so much for your interest in Living Bread!

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