New Client Intake Form

Date

PATIENT INFORMATION

First Name

Last Name

Middle Initial

Date of Birth

Age

Gender

Street Address

City

State

Zip Code

Phone

Email

Preferred Contact Method

Phone Email Text

Emergency Contact

Relationship

Phone

INSURANCE INFORMATION

Insurance Company

Member ID #

Policy Holder Name

Policy Holder Date of Birth

REFERRAL INFORMATION

If other, please explain

REASON FOR SEEKING SERVICES

If other, please explain

Briefly describe what brings you to counseling:

MEDICAL & MENTAL HEALTH HISTORY

Have you previously received counseling services?

Yes No

If yes, when and where?

Are you currently taking any medications?

Yes No

If yes, please list:

Do you have any current medical conditions?

Yes No

If yes, please describe:

CLIENT CONSENT

I understand that the information provided is accurate to the best of my knowledge and that completing this form does not guarantee services. I consent to being contacted by Advantage Mental Health and Wellness regarding scheduling and treatment services.

Yes No

Client/Guardian Signature:

Date: