Hope Behavioral Health Intake Form

Intake Form for Students

Hope Behavioral Health
Please note:
1. If the student is under the age of 18, a parent, custodial guardian, or a school representative must complete this form.
2. If the student is under the age of 18, only a parent, custodial guardian, or person with a medical POA can consent to services.
3. Prior to beginning services, we must have a signed release of information to be able to communicate with the school. You can find the release form here: https://hipaa.jotform.com/220134025352036
4. All items with a red asterisk (*) must be filled out before submitting form.
School information
Who is filling out this form?*
School system*
School building*
Name of school contact completing this form*

First NameLast Name
Email of school contact completing this form*
example@example.com
Phone number of school contact completing this form*
Please enter a valid phone number.
Student information
Student name*

First NameMiddle NameLast Name
Student date of birth*

MonthDayYear
Student address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student's gender*

MaleFemale
Student's grade*
Student's teacher (or homeroom teacher)*
Briefly tell us why the student is seeking services*
Parent/guardian information
Parent/guardian name*

First NameMiddle NameLast Name
Parent/guardian address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/guardian phone number*
Parent/guardian email
example@example.com
Is it OK to send you emails?*
Is it OK to send you text messages?*
Is it OK to leave you voicemails?*
Does student have primary insurance?*
Does student have secondary insurance?*
If applicable, please upload any custody documents:

Cancelof
Primary insurance information

Upon receipt of insurance information, our office will make every effort to verify your benefits and provide you with your projected out-of-pocket cost at your initial session. We would strongly recommend you call your insurance company and verify your benefits for outpatient mental health services. Some questions to consider asking: Do I have mental health insurance benefits? What is my deductible and has it been met? How many sessions per year does my health insurance cover? Is prior approval required from my primary care physician?
Please upload a copy of your insurance card front AND back. Multiple files can be selected for upload if needed.*

Cancelof
Please note that it is your responsibility to determine which insurance is your primary and secondary. Please indicate your primary insurance provider here:*
Policyholder name (if not student)

First NameLast Name
Policyholder date of birth (if not student)

MonthDayYear
Date
Policyholder address (if not student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary insurance information
Please upload a copy of your insurance card front AND back. Multiple files can be selected for upload if needed.*

Cancelof
Secondary insurance provider:
Policyholder name (if not student)

First NameLast Name
Policyholder date of birth (if not student)

MonthDayYear
Date
Policyholder address (if not student)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
*All information is transmitted and stored securely and privately using JotForm, conforming to HIPAA standards.
Should be Empty:

Intake Form for Students

School information

Student information

Parent/guardian information

Primary insurance information

Secondary insurance information