Bayside Therapy Associates Adult Intake Form printable pdf download

BAYSIDE THERAPY ASSOCIATES ADULT INTAKE FORM

INSTRUCTIONS: PLEASE COMPLETELY FILL OUT BOTH SIDES.

Date: _____________________ Form filled out by:

Self

Other: _____________________

Client Name: __________________________ Date of Birth: _____________ Age: ________

Gender:

Female Male ___________ Social Security #: ___________________________

Referred By: ______________________ Primary Care Doctor: __________________________

Address: __________________________________ City/State/Zip: _______________________

Home Phone #: _______________ Cell #: _______________ Work Phone #: ______________

OK to leave message?

YES NO

Employer: _____________________ Employer Address: _______________________________

Emergency Contact: Name: _____________________ Relationship to you: ______________

Home Phone #: _________________Cell #: _________________ Work #: _______________

SECONDARY INSURANCE

PRIMARY INSURANCE

No Insurance Coverage

Insurance Co.: ________________________

Insurance Co. Address: _________________

____________________________________

Insurance Co. Phone #: _________________

Client ID#: __________________________

Group/Plan #: ________________________

Policy Holder Name:___________________

Date of Birth:________ SS #:____________

Relationship to you: ___________________

Person Responsible for Account:

Self

Other (fill out below)

Name: ____________________________ Address: __________________________________

Home Phone #: _________________ Work: _______________ Cell: ____________________

SS#: ______________________ DOB: _____________ Employer: _____________________

FOR OFFICE USE ONLY

Dates of Referral: ______________ to _____________Date First Consulted:________________

Number of Sessions: ____________ Ded.: ___________Co-pay/Co-ins: ___________________

Date

dx code

Counselor Signature

(1)

Bayside Therapy Associates Adult Intake Form