Patient Information

This is an information-gathering intake form designed to cut down 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 complete ALL parts of the intake form. This will allow for a smoother intake process and less forms to sign. 

Thank you, 
Manna Treatment

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* 1. Name of Person Needing Services

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* 2. Date of Birth

Date

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* 3. Address

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* 4. Please provide the following details regarding person seeking services

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* 5. Please provide your social security number. If you do not provide this, we will be unable to bill your services and you will not be able to be seen at this practice.

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* 6. Please leave contact information that is the best for scheduling appointments, leaving messages, etc
It is to the discretion of the therapists and counselors who are a part of the Manna Treatment network regarding their availability after-hours and for phone consultations. Therapists will make every effort to return your phone call within a 24-hour time frame. Phone calls are subject to be prorated at the usual fee per session.

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* 7. Best Email Address to set up your Manna portal:

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