Hope Behavioral Health Intake Form

Intake form for new clients

Hope Behavioral Health
Welcome to Hope Behavioral Health.

In an effort to quickly and efficiently connect you with a therapist, this intake form collects all necessary and required information in order to begin counseling services. It only takes about 5-10 minutes to complete.

Please note:
- If the individual seeking services is under the age of 18, this form must be completed by a parent/legal guardian.
- You will need to upload copies of your driver's license and insurance cards (if you have insurance) before submitting this form.
Once this form has been submitted, we will contact you as quickly as possible. Upon receipt of your insurance information (if applicable), we will make every effort to verify your benefits and provide you with your projected out-of-pocket cost at your initial session. However, we strongly recommend you call your insurance company and verify your benefits for outpatient mental health services.

If you have any questions, please contact our intake department at (800) 642-4560, option 1.

Thank you,

Intake team
Hope Behavioral Health

*All information is transmitted and stored securely and privately using JotForm, conforming to HIPAA standards.
Overview
Is the individual seeking services 18 years or older?*

YesNo
Please note:

This form must be completed by a parent/legal guardian.
Will insurance be used for services?*

YesNo
*Please note:

It is required that you provide all insurances a client is covered by and indicate the order in which they are to be billed. Any discrepancies in relationship to this coordination of benefits will result in claim denials. This will be covered in the insurance sections below.
Does client have secondary insurance?*

YesNo
Do you have your insurance card(s) with you?*

YesNo
Please note:

Before submitting this form, you will need to upload a picture of the front AND back of your insurance card(s).
How did you hear about us?*

Online searchSocial media/blog postPsychology TodayFriend/family referralProfessional (Dr., hospital, etc.)ChurchSchoolOther
If you selected other, how did you find us?
Client information
Client name*

First NameMiddle NameLast Name
Client birth date*

MonthDayYear
Client address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email for correspondence (please use parent/guardian email address if client is under 18)*
example@example.com
Is it OK for us to send emails?*
Client mobile number*
Is it OK for us to leave voicemails?*
Is it OK for us to send text messages?*
Client home number
Client gender*

MaleFemale
Client marital status*

MarriedUnmarried
Client employment status*

EmployedNot employedDisabilityRetired
Please upload a picture of your driver's license.*

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Is the family currently involved in custody or divorce proceedings?*

YesNo
If yes, has a Guardian ad Litem (GAL) been assigned?*

YesNoN/A
Is there any legal documentation pertaining to the identified client (i.e. guardianship, custody, etc.)?*

YesNo
Please upload any related legal documents.*

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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 email address*
example@example.com
Is it OK for us to send emails?*
Parent/guardian mobile number*
Is it OK for us to leave voicemails?*
Is it OK for us to send text messages?*
Please upload a picture of your driver's license.*

Cancelof
Patient preferences
Briefly tell us why you are seeking therapy*
Client availability - please specify available days and times for routine appointments as this will be used in matching you with a therapist. Please be as specific as possible *
Type of counseling desired
NOTE: If you are interested in faith-based therapy, please keep in mind that although all of our therapists operate from a spiritually sensitive ethical position, not all of them incorporate faith-based principles in treatment. To ensure that you are assigned a therapist who is competent in this area, be sure to let us know here so that we can match you with a therapist to best meets your goals.
Do you wish to incorporate faith-based components (e.g. Biblical counseling and/or prayer) in your therapy sessions?*

YesNoIndifferent
Location preference
If the above location preference is unavailable, are you open to traveling to the next closest office location?

YesNo
If the above location preference is unavailable, are you open to telehealth?

YesNo
Preferred therapist
Second preferred therapist
If your above preferred therapist(s) is unavailable or availability does not match, may we match you with a therapist based on the information provided?

YesI wish to be contacted first about my other options
*Please visit http://www.hopebehavioral.com/therapists to see which therapists work out of a particular office.

*Assignment of therapists is ultimately subject to therapist and office availability as well as insurance contracts. We will make every effort to honor your preferences, but cannot guarantee it. Thank you for your understanding as we work to link you with a compatible provider.
Please upload a copy of your ID or the ID of the primary guardian/custodian if client is a minor*

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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 the FRONT of your insurance card.*

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Please upload a copy of the BACK of your insurance card.*

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Please note that is is your responsibility to determine which insurance is primary and secondary. Please indicate your primary insurance provider here:*
Please indicate your secondary insurance provider here:*
Policyholder name (if not client)
Policyholder date of birth (if not client)

MonthDayYear
Date
Policyholder address (if not client)
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 client)

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

MonthDayYear
Date
Policyholder address (if not client)
*All information is transmitted and stored securely and privately using JotForm, conforming to HIPAA standards.
Should be Empty:

Intake form for new clients

Overview

Client information

Parent/guardian information

Patient preferences

Primary insurance information

Secondary insurance information