Intake Form

INITIAL INTAKE FORM

BASIC

Full Legal Name (required)

Preferred Name/Alias

Maiden Name

Date of Birth (required)

Email (required)

Street Address (required)

City (required)

State (required)

Zip Code

Social Security Number

Phone (Cell) (required)

Phone (Alternate)
[cf7mls_step cf7mls_step-1 "Next" ""] INSURANCE

Health Insurance? (required)
YesNo

Medicaid or Medicare? (required)
YesNo

Primary Insurance Company

ID Policy Number

Group Number

Secondary Insurance Company (if applicable)

Secondary ID Policy Number

Secondary Group Number
[cf7mls_step cf7mls_step-2 "Back" "Next" "Step 2"]DETAILS "DETAILS

DETAILS

Gender (required)
—Please choose an option—FemaleMaleTransgenderOther

Race (required)
—Please choose an option—American Indian or Alaskan NativeAsianBlack or African AmericanHispanicNative Hawaiian or other Pacific IslanderOtherWhiteDecline to Specify

Ethnicity (required)
—Please choose an option—Not Hispanic or LatinoHispanic: Mexican AmericanHispanic: Puerto RicanHispanic: CubanHispanic: or LatinoDecline to Specify

Preferred Language (required)
—Please choose an option—EnglishFrenchItalianJapanesePortugueseRussianSign LanguageSpanishOtherDeclined to Specify

English Proficient?
YesNo

HOUSEHOLD
Living Arrangement (required)
—Please choose an option—Private ResidenceOther IndependentHomelessFoster FamilyOther

# Adults

# Children

Pregnant? (required)
YesNo

Marital Status (required)
—Please choose an option—AnnulledDivorcedDomestic PartnersMarriedNever MarriedMinorSeparatedWidowed

Employment Status (required)
—Please choose an option—EmployedUnemployedRetiredPart-TimeStudentMinor

Disabilities?
NoneHearingVisualAmbulatoryOther (please explain)
Comments

Smoker? (required)
YesNo

Frequency

Veteran? (required)
YesNo

Highest Level Education Completed (required)
—Please choose an option—Bachelors DegreeCompleted High School/GEDGraduate Degree or HigherLess than 12th GradeLess than 9th GradeLess than 6th GradeSome College[cf7mls_step cf7mls_step-3 "Back" "Next" "Step 3"] CONTACTS
Emergency Contact (required)

Relationship (required)

Emergency Phone (required)

Preferred Hospital

Family/Preferred Physician

Physician Office Name

Physician Phone

Attorney/Referral Source Name

Phone

Fax

Street Address

City

State

Zip Code

[cf7mls_step cf7mls_step-4 "Back" "Next" "Step 4"] HEALTH
Within the last 12 months, have you been treated or diagnosed with any of the following (select all that apply and explain) (required):
SeizuresDiabetesHigh Blood PressureHeart DiseaseBipolarDepressionBowel ProblemsSchizophreniaUlcersHepatitisCirrhosisChest PainCancerShortness of Breath Infectious DiseasesLiver ProblemsKidney ProblemsLung ProblemsAbscessSerious Infections PancreatitisHead InjurySurgeryBroken BonesTBHIVSTD'sPsychiatric Hospitalization Suicide AttemptsAddictionsEating DisordersVisual Impairments Hearing Impairments Speech ImpairmentsThreatened/Harmed OthersOther (please explain)None
Comments

Do you have any allergies? (required)
YesNo
Date of last physical exam (required)

Please list any over the counter and/or prescribed medications that you may be taking or prescribed and not taking (please include medication name, dosage, instructions & reason for and duration of a prescription) (required)

[cf7mls_step cf7mls_step-5 "Back" "Step 5"]