Intake Form

CRISIS LINE 988 Emergency 911

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Client Information

Full Name

Preferred Name

Social Security Number

Client is a Minor

Guardian Name

Phone Number

Date of Birth

Sex at Birth

Male Female

Gender

Male

Female

Other

Comments

Email address

Street Address

Apartment

City

Zip Code

Emergency Contact Name

Relationship to Client

Emergency Contact Phone Number

Insurance Information

Insurance Carrier (write none if client does not have insurance)

Member or Policy Number (Write none if client does not have insurance)

Group Number

Subscriber Information

Subscriber is Client Subscriber is other than client

Subscriber Name (if other than client)

Subscriber Date of Birth (if other than client)

Identification Card

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Please upload a file

Primary Insurance Card Front

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Please upload a file

Primary Insurance Card Back

Add file

Please upload a file

Secondary Insurance Card Front

Add file

Please upload a file

Secondary Insurance Card Back

Add file

Please upload a file

Requested Services

Scheduling

Additional Information (Optional)

Client was Referred to Roadways to Recovery

Referrer Name

Referrer Organization

Referrer Contact Number

Contact Email

Contact Fax

Please upload any pertinent documentation from referral sources

Medication List

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Please upload a file

Medical Eval

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Please upload a file

Therapy Notes

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Please upload a file

Someone will reach out to you with in 72 business hours. You will receive an email from Contact@roadwaystorecovery.com with consents to sign and to schedule. If you do not hear from us after 72 business hours please call 812-675-8849 or email Contact@roadwaystorecovery.com

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