New Client Intake Form printable pdf download

New Client Intake Form

Karmyn Vaughn, LICSW

MILL HOUSE COUNSELING

DOVER, NH 03820

(603)-742-1373 Ext: 116

New Client Intake Form

Name _________________________________________________________ Date __________________

Address ______________________________________________ City____________________________

State ________________________________________________ Zip ____________________________

Telephone (home) _____________________________________ Work____________________________

Cell Phone ___________________________ Email ___________________________________________

Age ________________ Date of Birth ____________Occupation ________________________________

Emergency Contact Name ___________________________________ Phone ______________________

Insurance Company ___________________________________________________________

Insurance Billing Address ____________________________________________________

Policy number ______________________________________________________________

Group Number _____________________________________________________________

Policyholder’s Name and Date of Birth and Address

_____________________________________________________________________________

Confirmed your mental health benefits & have met your deductible? YES___ NO____

Confirmed your Copay amount? YES___ NO___

*Please bring a copy of all your health insurance cards on your first appointment

Referred By ___________________________________________________________________________

Primary Reason for Appointment

How did you hear about my practice?

New Client Intake Form