| Date: -- (mm/dd/yy) | Referral Source:
Email address |
Client Information:
| Name: | DOB: -- ( mm/dd/yy) |
| SSN: | Sex: |
| Address: | City: |
| State: ZIP: | Phone - Home: Work: |
| School: | Grade Level: |
| Legal Guardian (if applicable) | |
| Relationship to Client: |
Insurance Information:
| Medicaid # Medicare # |
| Private/Self Pay EAP Contact Services |
| Primary Insurance: Phone |
| Address: | State: ZIP: |
| Name of Insured: | Relationship to Client: |
| Insured's DOB: -- (mm/dd/yy) | Insured's SSN: |
| Insured's Employer: | Insured ID #: |
| Insured's Policy # | Insured Group# |
| Insured's Address: | City: State: ZIP |
| Insured's Phone#: |
Presenting Problem (s):
Medication (s):
Scheduled for: Initial Intake Therapy
Evaluation (s):
| IQ/Achievment (ADHD) | Personality |
| Child Abuse | Parenting |
| Forensic | Other - |