Intake Form

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Today's Date

Reason for Visit(Required)

Therapy / Counseling, Psychological Assessment, Other

Patient Information:

Patient's Name(Required)

First Last

Patient's Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent / Guardian Information:

Parent(s)/Guardian(s) Name:(Required)

First Name

Last Name

Address *if different*

Street Address Address Line 2 City State ZIP Code

Email(Required)

Cell Phone(Required)

Are you the legal guardian?(Required)

Yes

Marital Status:

Emergency Contact - Name(Required)

Emergency Contact - Number(Required)

Insurance Information:

Primary Insurance Carrier

Policy Holder Name

Date of Birth

Employer

Member ID #

Group #

Secondary Insurance?

Yes

Signature(Required)

I authorize payment of medical benefits to the undersigned physician or supplier (Behavioral Solutions, LLC or Family First Center for Autism) for mental health services:

Printed Name(Required)

Signature(Required)

I authorize the release of any medical or other information necessary to process this claim:

Printed Name(Required)

Signature(Required)

Printed Name(Required)

Date(Required)

Intake Form

Patient Information:

Parent / Guardian Information:

Insurance Information:

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