Adult Intake Form

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Gender *
Would you like to add another contact number? *
Best time to call *
Emergency contact information
 NamePhone numberRelationship
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Responsible Financial Party

We require a credit card to be placed on file.  Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees.  Credit card information must be entered even if you are not the responsible party.
 
TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees. 
Is financial responsibility someone other than the patient? *
Visa
By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account. *

Referral Information

Presenting Problem

Treatment History

Prior OUTPATIENT psychotherapy? *
Dates if known.
Therapist information
 NameCity, StatePhone number
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Treatment Modality (check all that apply)
 
Has any family member had any mental health treatment? *

Notices

By checking this box, you acknowledge that you have read the notices above. *

Acknowledgement and Signature

By signing this form, you agree that you are willing to be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Clients are responsible for all payments at time of service. Clients who do not show up for follow-up appointments are subject to a $50 or $100 no-show fee which must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in you not being accepted as a client. *
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