Intake Evaluation Form Survey

1. Identifying Information

Identifying Information First Name
Last Name
Name you like to be called:
Spouse/Partner's Name:
Street Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Email:
Birthdate:
Social Security No:
Age:

2. Gender

Gender

3. Marital Status

Marital Status

4. Ethnicity

Ethnicity

Other (please specify)

5. Referral Source

Referral Source

Please specify above

6. Responsible Party

Responsible Party Responsible Party Name (If different from client):
Responsible Party Phone:
Responsible Party Address, City, Zip:

7. Insurance Information. If you would like me to bill your insurance company at no charge to you, please take out your insurance card and fill in ALL of the fields below. If the information is not on your card, please write NOT ON CARD in the appropriate field. Any missing information will delay billing your insurance company.

Insurance Information. If you would like me to bill your insurance company at no charge to you, please take out your insurance card and fill in ALL of the fields below. If the information is not on your card, please write NOT ON CARD in the appropriate field. Any missing information will delay billing your insurance company. Name of Insurance Company
Name of Person Who Holds the Insurance
Address of Insured
Insured's DOB
Phone Number of Insured
ID # of Insured
SS # of Insured
Group # of Insured
Plan Effective Date
Name of Plan
Type of Plan (HMO, PPO, etc)
Deductible (if known)
Address to Send Claims (On Card)
Customer Service Phone Number (On Card)
Name of Patient (if different from Insured)
SS # of Patient (if different from insured)
Patient's DOB

8. Employment

Employment

Employer

Intake Evaluation Form

1. Confidential Questionnaire