Patient Information

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. 

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. Gender of client

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* 5. Race of client

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

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* 7. 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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* 8. You can use the online client portal to view your upcoming appointments, view your account statement, make payments, and take assessments. What is the email address of the person needing services?

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