Adult Patient Intake Form printable pdf download

Adult Intake

Western Reserve Psychological Associates, Inc.

Date of Initial Visit _________________ WRPA Therapist______________________________________

Client Name_______________________________________________________________________________

Home Address_____________________________________________________________________________

Street

City

State

Zip

Home Telephone ____________________ Is it okay to call? Yes _____ No _____

Work Phone________________________ Is it okay to call? Yes _____ No _____

Cell Phone _________________________ Is it okay to call? Yes _____ No _____

Social Security Number______________________

Birthdate ___________________

Age _____

Male _____ Female _____

Marital Status S____ M____ W____ D____

Client Status: Employed ______

Full Time Student _______

Part Time Student _______

Highest Degree of Education _________________________________

Religion ____________________

Employer______________________________________________ Occupation _________________________

Employment Address________________________________________________________________________

Street

City

State

Zip

Name of spouse ____________________________________________________________________________

Social Security Number______________________

Birthdate ___________________

Age _____

Highest Degree of Education ___________________________

Religion _____________________________

Spouse’s employer ______________________________________ Occupation __________________________

Employment Address________________________________________________________________________

Work Phone________________________ Is it okay to call? Yes _____ No _____

Cell Phone _________________________ Is it okay to call? Yes _____ No _____

Names and ages of children (if applicable): ______________________________________________________

_________________________________________________________________________________________

Person responsible for deductible, coinsurance, and copayments if other than client:______________________

Address __________________________________________________________________________________

Street

City

State

Zip

Did you contact your insurance company to verify your benefits and let them know you were coming? ________

Deductible/year $_________ Has it been met?_______

Copayment/coinsurance/visit $_______ or _____%

Did you receive an authorization number from your insurance company? Yes_____

No_____

Authorization number ___________________________________________ Number of visits ______

Did you get a referral from your Primary Care Physician if required by your ins. co.? Yes_____ No_____

Insurance Information

For Secondary Ins. Only

Policy Holder's ID/SS#

____________________________

Policy Holder's ID/SS#

_______________________________

Ins Co. Name

____________________________

Ins. Co. Name

_______________________________

Policy Holder's Name

____________________________

Policy Holder's Name

_______________________________

Relationship to client

____________________________

Relationship to client

_______________________________

Policy Holder's Address

____________________________

Policy Holder's Address

_______________________________

____________________________

_______________________________

Policy/Group #

____________________________

Policy/Group #

_______________________________

Policy Holder's DOB

____________________________

Policy Holder's DOB

_______________________________

Male _____ Female _____

Male _____Female _____

Employer

____________________________

Employer

_______________________________

How did you hear about our practice? ___________________________________________________________

May we thank your referral source? Yes _____ No____ If yes, referral address___________________________

Did you search for more information about us on the internet? _______

Did you use a search engine? Yahoo _____, Google _____, AltaVista _____, Other ______________________

Did you visit our website? _______ For what purpose? _____________________________________________

When you decided to call us, where did you get our phone number?_________________________________

Adult Patient Intake Form

Related Articles

Related forms

Related Categories