AdultIntakeForm

Adult Intake Form

Patient and Insurance Information

Name*

Date of Birth*

Gender

Male Female Non-binary Prefer to self-describe

0 of 64 max characters

Email*

Phone*

Address

Emergency Contact Information

Referral Source

Social Security Number (optional)

Employment

Employed Unemployed

Employer

Are you looking for specific services?

Medication management Psychological Testing Talk Therapy TMS and Spravato

PCP Information

Primary Care Physician

Past mental health treatment providers

Phone

Fax Number

Address

Preferred Office Location

Are you seeking a specific provider?

Are you currently on any mental health meds?

Yes No

Were you referred specifically for neuropsychological testing?

Yes No

If yes, why was testing suggested and will this be the first time you have had testing performed?

What are you looking for help with?

Insurance Information

Patient relationship*

Self Spouse Child

Policy holder's name*

Name of Insurance*

Policy Number*

Policy holder's date of birth

Do you have a SECOND insurance where claims should be submitted?

Yes No

If so, second insurance name

I Agree to terms*

By checking the "I Accept" box, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting "I Accept" you consent to be legally bound by this agreement's terms and conditions and all terms listed above.

Thank you for your submission!

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