Behavioral Health Providers General Intake Form

Behavioral Health Provides General Intake Form

Please fill out as much of the following Behavioral Health Providers General Intake Form as you can.

Behavioral Health Providers will only use the information you provide on the General Intake Form for treatment and billing purposes.

We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

General information for first session

Behavioral Health Providers needs you to fill out all of the following information about you and your employer for treatment and billing purposes.

Patient Information

Name *

First

Middle

Last

Birth date *

Gender you Identify as

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Employer Information

Please supply the following information about your employer as required by most insurance companies.

Employer

Employer Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Patient Prefered Contact Method

We will make every effort to only contact you by your prefered method listed below.

Home Phone

Home Phone Contact Preference

• Ok to call / message
• Do not call / message

Mobile Phone

Mobile Phone Contact Preference

• Ok to call / message
• Do not call / message

Work Phone

Work Phone Contact Preference

• Ok to call / message
• Do not call / message

Email *

By hitting submit to return this form to Behavioral Health Providers, P.C. I acknowledge, affirm, and certify the following.
I have read this Behavioral Health Providers General Patient Information Form carefully.
I have filled in this form completely and to the best of my ability.

Submit

Behavioral Health Providers Additional Forms

• INSURED / GUARANTOR ACKNOWLEDGEMENT OF RESPONSIBILITY FOR PAYMENT OF SERVICES
• INFORMED CONSENT FOR TELEVISITS FORM
• FINANCIAL & TREATMENT POLICY
• PRIMARY CARE PHYSICIAN NOTIFICATION OF CLINICAL SERVICES AND CONSENT FOR THE RELEASE OF INFORMATION
• TREATMENT OF A MINOR CONSENT FORM