Patient Information

This is an information-gathering intake form designed to reduce time spent in the waiting room completing information.
Please 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 fewer forms to sign.

Thank you,
Manna Treatment
770-495-9775 (front office)

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1. First Legal Name of person receiving services (Required.)

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2. Last Name of person receiving services

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3. Address (Required.)

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4. Date of Birth (Required.)

Date

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5. Age of person needing services

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6. Gender of client (Required.)

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7. Race of client (Required.)

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8. Is the client:

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9. How did you find Manna?

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10. Please leave a phone number that is the best for scheduling appointments, leaving messages, etc. It is at 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. (Required.)

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11. We 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? (Required.)

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