This is an information-gathering intake form designed to reduce time spent in the waiting room completing information. Please be ready to have the following to complete the form:
- Basic information on the person being seen for therapy (age, DOB, address, etc_
- Insurance information, including images of the insurance card
- Individual who is authorized to legally sign for treatment (adult, adult caregiver)
Please note that in order to be scheduled, you will have to provide your social security number. If you are unable to provide your social security number, you will not be seen at this practice.
FMLA: Please note that Manna clinicians do not complete FMLA (Family and Medical Leave Act) paperwork. We are not able to complete any paperwork or documentation to satisfy FMLA requirements.
Please complete ALL parts of the intake form. This will allow for a smoother intake process and less forms to sign.