Language
English (US)
Thank you for your interest in Zohar Health!
Please call us at (301)
250-0404 for
the access code for the online Intake Form.
Access Code
*
Please enter the access code, then hit next, to gain access to this form.
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New Client Intake Form
Phone: (301) 250-0404 | Fax: (301) 637-7970 | ZoharHealth.com
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
What is your gender identity?
*
Male
Female
Do not identify as either
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Did someone refer you?
*
Yes
No
Name of the person you referred you:
Relationship:
Doctor
Therapist
Other
What is the highest level of education you have completed?
*
Less than High School
GED
High School
Some College credits
Associates
Trade School
Bachelors Degree
Masters Degree
Doctoral
Are you currently employed?
*
Yes
No
Employment details
*
Part Time
Full Time
Employed, but currently on disability
Employed, but currently collecting workers compensation
Are you currently a student?
*
Yes
No
Are you a full time student or part time student?
*
I am currently a FULL TIME student.
I am currently a PART TIME student.
Do you have a primary care provider?
*
Yes
No
Have you had mental health care before?
*
Yes
No
Are you currently in therapy?
*
Yes
No
Name of therapist
*
First Name
Last Name
Date of last visit
*
-
Month
-
Day
Year
Date
Have you had psychiatric medication management?
*
Yes
No
Name of recent/previous psychiatric prescriber
*
First Name
Last Name
Date of last visit
*
-
Month
-
Day
Year
Date
Reason for leaving
*
Please list all current medications you are taking.
*
What are your goals and expectations from treatment?
*
Have you ever tried to harm yourself & needed medical attention?
*
Yes
No
Have you harmed others in the past requiring medical and or legal attention for you or other party?
*
Yes
No
Have you had inpatient psychiatric admission?
*
Yes
No
If yes, how many times?
1
2
3
More than 3
Have you had substance abuse treatment like detox or rehab?
*
Yes
No
If yes, how many times?
1
2
3
More than 3
Do you have any addictive behavior like gambling?
*
Yes
No
Do you take prescription pain medication?
*
Yes
No
Do you have current legal issues?
*
Yes
No
Are you planning to apply for sick leave, disability, accomodation at work or school, apply for FMLA, help with legal issues or immigration due to mental health reasons?
*
Yes
No
Please check the box below to consent
*
I understand initial intake does not constitute an agreement for treatment. I hereby consent Zohar Health to access my medication prescription record history from Surescript and PDMP in NY/MD /DC.
Insurance and Billing
Are you a self-pay client?
Yes
No
Please upload a copy of your driver's license / ID
*
Please upload the front and back of your insurance card
*
Browse Files
Cancel
of
Are you the guarantor of your health insurance?
*
Yes
No
If you are not the guarantor of your health insurance please provide the following:
Guarantor's Name
First Name
Last Name
Guarantor's Date of Birth
-
Month
-
Day
Year
Date
Relationship to Client
ex: spouse, child
Guarantor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have secondary insurance?
*
Yes
No
Please upload front and back of your secondary insurance card.
Browse Files
Cancel
of
Signature
*
Client Name
*
First Name
Last Name
City
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: