Hope Behavioral Health Intake Form

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 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.

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?*

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 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 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.*

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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

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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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.*

function SvgDhtupload2(props) { return /* @__PURE__ */ react.createElement("svg", dhtupload_svg_extends({ width: 54, height: 47, xmlns: "http://www.w3.org/2000/svg" }, props), dhtupload_svg_path || (dhtupload_svg_path = /* @__PURE__ */ react.createElement("path", { d: "M40.213 10.172c1.897.21 3.68.738 5.35 1.58a15.748 15.748 0 0 1 4.374 3.242 15.065 15.065 0 0 1 2.951 4.533c.72 1.704 1.08 3.522 1.08 5.455 0 1.827-.28 3.654-.843 5.48-.562 1.828-1.379 3.47-2.45 4.929A13.39 13.39 0 0 1 46.669 39c-1.599.948-3.452 1.458-5.56 1.528H37.26a1.62 1.62 0 0 1-1.185-.5 1.62 1.62 0 0 1-.501-1.186c0-.457.167-.852.5-1.186.334-.334.73-.5 1.186-.5h3.848c1.44 0 2.75-.37 3.926-1.108a10.851 10.851 0 0 0 3.03-2.846 13.53 13.53 0 0 0 1.95-3.9 14.23 14.23 0 0 0 .686-4.321c0-1.582-.316-3.066-.949-4.454a11.623 11.623 0 0 0-2.582-3.636 12.857 12.857 0 0 0-3.742-2.478 11.054 11.054 0 0 0-4.48-.922l-1.212-.053-.37-1.159c-.878-2.81-2.292-4.998-4.242-6.562-1.95-1.563-4.594-2.345-7.932-2.345-2.108 0-4.005.36-5.692 1.08-1.686.72-3.136 1.722-4.348 3.005-1.212 1.282-2.143 2.81-2.793 4.585-.65 1.774-.975 3.68-.975 5.718h.053l.105 1.581-1.528.264c-1.863.316-3.444 1.317-4.744 3.004-1.3 1.686-1.95 3.584-1.95 5.692 0 2.39.8 4.462 2.398 6.219 1.599 1.757 3.488 2.635 5.666 2.635h4.849c.492 0 .896.167 1.212.5.316.335.474.73.474 1.187 0 .456-.158.852-.474 1.185-.316.334-.72.501-1.212.501h-4.849a10.08 10.08 0 0 1-4.374-.975 11.673 11.673 0 0 1-3.61-2.661 13.173 13.173 0 0 1-2.478-3.9A12.073 12.073 0 0 1 0 28.301c0-2.706.755-5.148 2.266-7.326 1.511-2.178 3.444-3.636 5.798-4.374.14-2.354.658-4.542 1.554-6.562.896-2.02 2.091-3.777 3.584-5.27 1.494-1.494 3.25-2.662 5.27-3.505C20.493.422 22.733 0 25.193 0c1.898 0 3.637.237 5.218.711 1.581.475 3.004 1.151 4.269 2.03a13.518 13.518 0 0 1 3.268 3.215 18.628 18.628 0 0 1 2.266 4.216Zm-11.964 13.44 6.22 6.85c.245.247.368.537.368.87 0 .334-.123.642-.369.923l-.421.263c-.211.246-.484.343-.817.29a1.544 1.544 0 0 1-.87-.448l-3.69-4.11v16.97c0 .492-.166.896-.5 1.212-.334.316-.729.474-1.186.474-.492 0-.896-.158-1.212-.474-.316-.316-.474-.72-.474-1.212V28.25l-3.584 4.005a1.544 1.544 0 0 1-.87.448.959.959 0 0 1-.87-.29l-.42-.264c-.247-.28-.37-.588-.37-.922 0-.334.123-.624.37-.87l6.113-6.746v-.052l.421-.422a.804.804 0 0 1 .396-.29c.158-.053.307-.079.448-.079.175 0 .333.026.474.079.14.053.281.15.422.29l.421.422v.052Z", fill: "none" }))); }

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)

Date

Policyholder address (if not client)

Please upload a copy of your insurance card front AND back. Multiple files can be selected for upload if needed.*

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Secondary insurance provider:*

Policyholder name (if not client)

First NameLast Name

Policyholder date of birth (if not client)

Date

Policyholder address (if not client)

*All information is transmitted and stored securely and privately using JotForm, conforming to HIPAA standards.

Intake form for new clients

Overview

Client information

Parent/guardian information

Patient preferences

Primary insurance information

Secondary insurance information