Medical Intake Form
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3INTAKE FORM
Thank you for taking the time to completely fill out this form as it will help us to better understand you
and your situation. The information you provide here is confidential and will only be shared with your
clinician.
IDENTIFYING INFORMATION
Name
Last
First
Middle
Former Name(s)
Address
Street
City
State
Zip
Home:
Cell:
Work:
Telephone
Today's Date
DOB
Age
General
Number of years of education
Social Security #:
Employer Name
Occupation:
Present Occupation
Hispanic or Latino Non-Hispanic or Latino Decline
Ethnicity:
American Indian Alaska Native
Asian
White
Race:
Native Hawaiian Other Pacific Islander
African American Decline
English Spanish Hmong Mandarin Other __________________________
Language
INSURANCE INFORMATION
Source/Company:
Group#:
Subscriber#:
HEALTHCARE HISTORY
Do you have a regular physician?
Yes
Name
Phone
Address
No
Do you want a summary sent to this person (as listed above)?
Yes
No
Yes
Who sent you? _________________________________________________
Were you referred here by someone?
Address: ______________________________________________________
No
Do you want a summary sent to this person?
Yes
No
What are the major
concerns or issues that
bring you to Driftless?
List any previous mental
health therapy you have
had.
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Parent category: Business