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Application Intake Form

Personal Information

Prefix

First Name

Middle Name

Last Name

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of Birth

Gender

Social Security Number0 / 11

Marital StatusSingleMarriedDivorcedWidowedSeparated

Phone NumberPrimary Contact Number

Preferred Method of ContactPlease tell us your preferred way to be contacted.

Email AddressPlease enter a valid email address we can contact you at.

Confirm Email Address

Emergency Contact Information

Prefix

First Name

Middle Name

Last Name

Emergency Contact Phone

Relationship to Applicant

Prefix

First Name

Middle Name

Last Name

Emergency Contact Phone

Relationship to Applicant

Prefix

First Name

Middle Name

Last Name

Emergency Contact Phone

Relationship to Applicant

Insurance Information

Insurance Provider

Policy/Group Number

Subscriber's Date of Birth

Subscriber's Name

Medical History

Do you have or have you ever had any of the following medical conditions?DiabetesHigh Blood Pressure (Hypertension)Heart DiseaseAsthma/Breathing ProblemsSeizuresAllergies (Food, Medicine, EnvironmentalCancerOther (Please specify belowOther

If you selected "Other" or would like to provide more details, please explain.

Past Surgical History

Hospitalizations

Do you have any history of mental health conditions?YesNo

Please indicate if you have experienced any of the following mental health conditionsAnxietyDepressionPTSDBipolar DisorderOther

Please explain any mental health conditions.This information will help us better uderstand your health needs>

Are you currently taking any prescribed medications?YesNo

If yes, please list the medications you are currently taking.This information helps us better understand your care needs.

Substance Use History

Do you currently use alcohol, tobacco, or drugs?If yes, please specify type, frequency, and amount in the space provided.YesNo

Details of alcohol, tobacco, or drug use (if applicable)

Criminal History

Have you ever been convicted of a crime?NoYes

Are you currently on probation, parole, incarcerated, or facing any pending charges?NoYes

If yes, please provide details about your legal conviction and status.This information will only be used to understand your background.

About Yourself

What name do you like to go by?We’ll use this name when we address you.

What are some things you enjoy doing in your free time?Sharing your interest helps us get to know you better.

What personal goals are you currently working on?

Is there any additional information you would like to share?This can include anything about your health, personal situation, or background that you feel is important for us to know.

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