Pre-Intake Screening Form

Thank you for your interest in care. Submitting this form allows us to review your information and determine whether our clinic is the best fit. If your needs are outside our scope of care, we will provide referral options for other providers or higher-level services.

Completion of this form does not establish a patient–provider relationship.

This form is not monitored for emergencies. If you are in crisis, experiencing thoughts of harm to yourself or others, or need immediate assistance, please call 988 (Suicide & Crisis Lifeline), dial 911, or go to your nearest emergency department.

About You

What is your legal first and last name?

If you have a preferred name, please type it here.

Date of Birth

Please enter your phone number, including area code.

What is your email?

Please type the address where you currently reside, including city, state, and zip code.

Reason for Seeking Care & Brief History

These questions help us ensure that our clinic can safely meet your needs.

What is your primary reason for seeking care? (Example: anxiety, mood changes, difficulty sleeping, medication concerns, etc.)

What are your main concerns or goals for treatment right now?

Additional Information

What days/times are best for appointments?

Please type the name of your insurance provider (if applicable)

Is there anything else important that you would like us to know?

Acknowledgement/Consent

Please read and check the following before submitting:

I understand that the information I provide in this form is confidential and protected under HIPAA. By submitting this form, I consent to Pelican Behavioral Health using this information to contact me and review my suitability for services. I understand that my information will be securely stored and will not be shared without my permission, except as required by law (such as to ensure safety).

I understand that this form is not monitored for emergencies. If you are in crisis, experiencing thoughts of harm to yourself or others, or need immediate assistance, please call 988 (Suicide & Crisis Lifeline), dial 911, or go to your nearest emergency department.

I understand that Pelican Behavioral Health may communicate with me by phone, voicemail, text message, email, or through the secure SimplePractice Client Portal. I acknowledge that while every effort is made to protect my privacy, email and text messaging may not be fully secure.

I understand that I may revoke this consent at any time by providing written notice to Pelican Behavioral Health.

I confirm that I’ve answered this form honestly and to the best of my ability. I understand that my typed name below serves as my electronic signature.

Type Signature Here:

Current Date:

Your information will be encrypted.