Intake Form - Counseling Life Wellness
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1
2Janice Motoike, Ph.D., P.L.L.C.
Intake Form
1
INTAKE FORM
DATE:
REFERRED BY:
PATIENT INFORMATION
NAME:
DOB:
AGE:
ADDRESS:
CITY:
STATE:
ZIP CODE 9-digit
TELEPHONE (HOME):
(CELL):
(WORK):
PREFERRED PHONE
HOME
CELL
WORK
E-MAIL*
*for appointments and notifications only
GENDER:
MALE
FEMALE
OTHER
ETHNICITY:
MARITAL:
SINGLE
SIGNIFICANT OTHER
MARRIED
SEPARATED
DIVORCED
WIDOWED
DRIVER’S LICENSE #:
SOCIAL SECURITY #:
EMPLOYER:
OCCUPATION:
EMERGENCY CONTACT:
RELATIONSHIP:
TELEPHONE (HOME):
(CELL):
(WORK):
NEXT OF KIN:
RELATIONSHIP:
TELEPHONE (HOME):
(CELL):
(WORK):
MOTHER’S MAIDEN NAME
FIRST NAME
PRIMARY INSURANCE INFORMATION
INSURANCE COMPANY:
PHONE:
HOLDER’S DOB:
POLICY NUMBER:
EMPLOYER:
GROUP NUMBER:
GUARANTOR (POLICY HOLDER) INFORMATION
GUARANTOR NAME:
DOB:
AGE:
ADDRESS:
CITY:
STATE:
ZIP:
TELEPHONE (HOME):
(CELL):
(WORK):
SOCIAL SECURITY #:
RELATIONSHIP TO PATIENT:
EMPLOYER:
GROUP NUMBER:
SECONDARY INSURANCE INFORMATION
INSURANCE COMPANY:
PHONE:
POLICY HOLDER:
RELATIONSHIP:
HOLDER’S DOB:
POLICY NUMBER:
EMPLOYER:
GROUP NUMBER:
Rev 2016 1127
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