Secure Intake Assessment Form

Name:

Address:

City, St, Zip:

Email Address:

Home Phone:

 (with area code)

    May we call you at home?     Yes No

EMPLOYER:

Work Phone:

 (with area code)

    May we call you at work?     Yes No

Cell Phone #:

 

Sex:     Male Female

Date of Birth:

MARITAL STATUS:
Married Single
Divorced Separated Widowed

SPOUSE OR PARENTS(S) NAMES(S):

Date of Birth:

If client is a child

School:


THERAPIST REQUESTED:  We Can not Guarantee Therapist Availablity

REFERAL SOURCE:          If Other  

PRESENTING PROBLEM: (briefly describe why counseling is being sought at this time)


INSURANCE INFORMATION

Insurance Company:

Name of Policy Holder:
SS#:

Employer:
DOB of Policy Holder

Comments:
*Please contact your Insurance Company regarding co-payments and deductables.

Insurance considerations:

Does your plan provide for outpatient conseling? Percent of coverage? Have you met your deductable?

What credentials does the provider need to have for coverage to be considered?

Ph. D.        MSW        MSW with supervision by a Ph. D.        Ltd. Lic. Psychologist



TIMES AVAILABLE FOR APPOINTMENTS:
            

May we Email an information packet to you at the above email address?     Yes No

May we mail an information packet to you at the above street address?     Yes No




2019 Rambling Road   Kalamazoo, Michigan 49008   Phone: 269.345.0909

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