Internal Intake Form

Name of person needing services:

First Name *

Last Name *

Date of birth

Parent / Caregiver

Email *

Phone *

Address

Street Address 2

City

State

Postal code

Presenting Problem

If the patient is a minor, we will need consent from both parents/caregivers. We will also need a copy of the custody agreement/divorce decree before we can start services.

Parent / Caregiver Marital Status

Married

Separated

Divorced

Never Married

Widowed

Domestic Partners

We try to accommodate our client's scheduling needs; however, after school and weekends are the most requested times. If you have more flexibility in your schedule, we will be able to get you in sooner.

Availability

Insurance

Not planning to use insurance

Cigna

Aetna

Blue Cross Blue Shield

Humana / United Health Care

Other

Referral Source

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