Individual Intake

Client's Full Name: *

Age *

Birthdate *

SSN# *

Marital Status *

Today's Date *

Home Phone *

Cell Phone

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Address *

City *

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Zip *

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Phone

Employer or School (If Student) *

Emergency Contact Name *

Relationship *

Phone *

Insurance Information

Insurance Company *

Insured's SSN # *

Insured's Policy # *

Insured's Employer *

Name of Insured *

Insured's DOB *

Insured's Group # *

Amount of Copays *

Insured's Relationship to Client *

Authorization # *

If your counseling is being paid for through an employee assistance program, please list authorization number and how many sessions are being authorized.

EAP Company:

Authorization #:

# of Sessions:

Have you called your insurance for pre-authorization? *

Yes

If yes, list pre-authorization # / Name:

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Individual Intake

Insurance Information

If your counseling is being paid for through an employee assistance program, please list authorization number and how many sessions are being authorized.

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