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Intake Evaluation Form
*about 30 minutes to complete

1. Demographic and Insurance Information

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* 1. 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:

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* 2. Gender

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* 3. Marital Status

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* 4. Ethnicity

Other (please specify)

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* 5. Referral Source

Please specify above

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* 6. Responsible Party (if different than client)

Responsible Party Name:

Responsible Party Phone:

Responsible Party Address, City, Zip:

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* 7. Insurance Information. Please read carefully.

As of January 2023, I am not accepting the "in-network" contractual reimbursement rate I have with BLUE CROSS and CIGNA insurance. This means that if you choose to go forward using one of these insurances your copay will be higher than if you utilized another "in-network" provider. I am still willing to bill your insurance and accept their reimbursement rate as part payment but your copay will be the difference between the actual reimbursement rate and my standard fee which is $195 per session. If this is unacceptable to you (which I completely understand), I am sorry I am not in a position to accept your insurance and so it might serve you to seek another in-network provider.

If this is acceptable, please complete your insurance information below or text me a copy of your insurance cards front and back (949-295-9203) in lieu of completing the information below.

(By continuing to complete the information below, I am in agreement with the insurance arrangement above)

Name of Primary Insurance

Name of Secondary Insurance

Name of Person Who Holds the Insurance

Address of Insured

Insured's DOB

Phone Number of Insured

ID # of Insured

ID # of Secondary Insurance

SS # of Insured

Group # of Insured

Name of Primary Plan

Name of Secondary Plan

Type of Plan (HMO, PPO, etc)

Deductible (if known)

Your copay

Name of Patient (if different from Insured)

SS # of Patient (if different from insured)

Patient's DOB

Additional Information (authorization #, # sessions authorized, etc)

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* 8. Employment

Employer

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8% of survey complete.