General Intake Form - Jewish Family Services printable pdf download

For JFS admin to complete:

Fax to: 804-673-2061

Clinician _____________________

Appt. date/time ________________

Case #: _____________________

Jewish Family Services

GENERAL INTAKE

Date: __________

Please circle one: New Client or Returning Client

Services Requested:

Counseling _____

Psychological Evaluation (and/or testing) _____

Person completing this form (circle):

Self /Client Parent/Guardian Case Worker Other ________

Person completing this form contact information (if not the client):

Name: __________________________ Agency: ___________________________

Ph.# ____________________________ Fax# _____________________________

CLIENT’S PERSONAL INFORMATION (PLEASE PRINT):

Name: Mr. Mrs. Ms. Miss ________________________ ___ ______________________________

(FIRST)

(M.I)

(LAST)

Address: _______________________________________________________________________

(STREET ADDRESS)

(APT#)

(CITY)

(STATE)

(ZIP)

City/County of Residence: _________________

Phone: (H) ___________________ (W) ___________________ (C) ______________________

Preferred Contact # ______________________

INSURANCE INFORMATION. PLEASE ATTACH A COPY OF INSURANCE CARD

1) Company Name: ___________________________________ Telephone: __________________

Policy Holder: _______________________ DOB: ___________ Relation to Client: ___________

Employer: _________________________ Policy #:__________________ Group#: ___________

2) Company Name: ___________________________________ Telephone: __________________

Policy Holder: _______________________ DOB: ___________ Relation to Client:____________

Employer: _________________________ Policy #:__________________ Group#: ___________

STATISTICAL INFORMATION:

Birth Date: __/___/___

SSN:______-______-______

Marital Status: ________________

Yearly Income: $0-10,000: ___ $10-14,999: __ $15-24,999: __ $25-34,999: ___ $35-49,999: __

$50,000 +: ___

Veteran: Yes ____ No ____

Religion:

Gender:

JEWISH__ CATHOLIC __ PROTESTANT __ BUDDHIST ___ MUSLIM ___ OTHER ___

M ___ F ___ Other___

Race

WHITE __ AFRICAN AMERICAN __ NATIVE AMERICAN __ HISPANIC__ ASIAN___TWO OR MORE ____ OTHER __

COMMENTS/ADDITIONAL INFORMATION:_______________________________________

_________________________________________________________________________________

__Advertising

__Friend/Family

__Internet

__MD

__United Way

How did you hear about JFS?

__CAAA

__Govt. Agency

__Jewish Affiliation

__Mental Health Prof.

__Visit/Presentation

__Ref’d by JFS Client

__Adult Care Facility

__Current or Former Svc. At JFS __Insurance Referral

__ Mailing/Flyer

__Self

__Community Svc. Agency

__Home Health Agency

__Religious

__ Yellow Pages

__Ref’d by JFS Staff/Board