Intake Form

Intake Form
Client Data Sheet
Today's Date:

Month Day Year
Date
Name

First Name Middle Name Last Name
E-mail
Cell Number:

Area Code Phone Number
Is it ok to leave detailed message?
Home Number:

Area Code Phone Number
Is it ok to leave detailed message?
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth

Month Day Year
Sex
Marital Status
Employment Status
Medical Insurance Information

(Skip this section if you are going to pay out of pocket)
Have you called your insurance company and completed the "Insurance Form" ?

YES NO Paying out of Pocket: Not Applicable
If you are planning to use your insurance and you nswered "NO"; please go to the "Form's Page" of our website, relationshiprediscoverycenter.com, print off the "Insurance Guidance and Insurance Form". Clear guidance is provided for each steps for you to collect all the information you will need. You will need this information to determine if your insurance will cover these services and to deterrmine your cost. This call reduces the chances of unexpected bills. As a reminder: you are responsible for the fees when these services are not covered by your insurance.
Insurance Company:

Anthem / Blue Cross Blue Shield Beacon Health Cigna Harvard Pilgrim Health Plans Inc Humana Maine Community Health Options Patient Advocates LLC UMR United Health Care
At this time this office is unable to bill for Aetna, Maine Care, Medicare, Tricare. If you have these insurances, services are still possible by paying out of pocket. Fee reductions may be possible, see web site or call Bill.
Member ID:
Group Number:
"Payor ID" if noted on card
Not all cards note the payer ID: IF listed it usually is in the fine print on the back. If there is no "Payor ID" listed, leave blank.
Insurance Company Phone Number: If there are multiple numbers listed: please note "behavioral Health" or "Provider Services" number.

Area Code Phone Number
Emergency Contact

If coming as a couple please list someone other than your partner.
Emergency Contact:

First Name Middle Initial Last Name
Relationship
Contact Number

Area Code Phone Number
Medical Providers

Please fill in available information
Primary Care Provider Name
Check here if you currently DO NOT have a Primary Care Provider and move on to the next section
Primary Care Provider's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of last Appointment with Primary Care Provider, estimate okay.

Month Day Year
Date
Psychiatrist or Medication Manager's Name
Check here if you currently DO NOT have a Psychiatrist or Medication Manager and move on to the next section.
Psychiatrist or Medication Manager's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of last Appointment with Psychiatrist or Medication Manager, estimate okay

Month Day Year
Date
Medications
Are you taking any medications, currently?

Yes No
If yes, please list them here.
If lengthy you may forward a full copy separately.
Allergies:
Who referred you? How did you learn about these services?

PHQ-9

Depression screening: (Please note: The PHQ-9 and the GAD-7 look very much alike but have different questions)
Name

First Name Last Name
Today's date

Month Day Year
Date
Over the last 2 weeks how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
2. Feeling Down, depressed or hopeless
3. Trouble falling asleep or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or over eating
6. Feeling bad about yourself or that you are a failure or have let yourself or family down
7. Trouble concentrating on things, such as reading or watching TV
8. Moving or speaking so slowly that others could have noticed. Or the opposite, being so fidgety that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting yourself.
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?

GAD-7

Anxiety Screening: (Please note, The GAD-7 and the PHQ-9 look alot alike, however the questions are different.)
Name

First Name Last Name
Today's date

Month Day Year
Date
Over the last 2 weeks how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Intake Form

Client Data Sheet

Medical Insurance Information

Emergency Contact

Medical Providers

Medications

PHQ-9

Over the last 2 weeks how often have you been bothered by any of the following problems?

GAD-7

Over the last 2 weeks how often have you been bothered by any of the following problems?