HRHS Intake Form

Intake Form

Please complete all fields below and submit prior to your first session
Client Personal Information
Full Name *

First Name Middle Name Last Name Suffix
Preferred Name

First Name Last Name
Parent/ Guardian Name (if under 18)

First Name Middle Name Last Name Suffix
Cell Phone Number *

Area Code Phone Number
May we leave a message?

Yes No
Home Phone Number

Area Code Phone Number
May we leave a message?

Yes No
E-mail *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date *

Month Day Year
Biological Sex *
Gender Identity *
Preferred Pronouns *
Marital Status *
Spouse's Name
Employment Status *
Occupation
Do you currently enjoy your work and/or find anything about it stressful?
Emergency Contact Name *
Emergency Contact Phone Number *
Primary Care Provider
Primary Care Provider Phone Number
Do you have an appointment scheduled? *
Clinician you are scheduled with: *
How were you referred to our office?

Financial Information
How I plan to pay for treatment (select all that apply): *

I want to pay by cash I want to pay by check I want to pay by credit card I plan to use my insurance benefits
In the event that you would like to store your credit card information in our secure Square merchant system to pay for therapy, please complete the following fields:
Cardholder Name

First Name Last Name
Credit Card Number
Security Code
Expiration Month
Expiration Year
Billing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I, as the cardholder, hereby authorize Hope Rising Health Services, LLC to charge my credit card for any copays and balances due for therapy and confirm that the information for the credit card and billing address is complete and accurate.

I further understand that in the event that I fail to cancel my appointment prior to the required 24 hrs notice, or in the event that I do not show for my scheduled appointment, Hope Rising Health Services, LLC will automatically charge my credit card the respective fee as laid out in writing in the Informed Consent for Treatment.
Cardholder Signature

Clear

Insurance Information

If not using insurance, please type or select self-pay in the required fields
Primary Member ID # *
Clients Insurance card number
Primary Insurance Company name *
If other please complete below.
Secondary Insurance Company
Secondary Member ID #
EAP Program Name (if applicable)
EAP Authorization Number
Number of Approved Sessions
EAP Authorization Start Date

Month Day Year
Date
EAP Authorization End Date

Month Day Year
Date
Member Date of birth *
Clients Birth date
Sponsors Name *
Person who carries the insurance
Sponsors Date of birth *
Person who carries the insurance
Sponsors complete home address *
Person who carries the insurance
Insurance company telephone #
Attach front and back of Insurance card & Driver's License/ ID card

Browse Files
PDF, DOC, TIFF, JPEG Files only. Cancel of
By signing below, I am indicating that I give Hope Rising Health Services, LLC permission to contact my insurance and/or EAP benefits company as needed for benefits information, claims submission, and billing purposes on my behalf:

Clear

History of the Present Problem
What significant life changes or stressful events have you recently experienced? *
Have you ever experienced the same or a similar problem?

Yes No
If yes, please describe:
What would you like to accomplish from your time in therapy?

Signature and Submission
Please type your name below and then sign where indicated to consent to treatment.
Client Name:

First Name Middle Name Last Name Suffix
Client Signature *

Please draw your signature in the above box Clear
Date *

Month Day Year
If client is a minor, a parent or guardian must sign below to consent to the minor receiving treatment.
Parent/Guardian Signature

Please draw your signature in the above box Clear
Date

Month Day Year
Please check the box *
Should be Empty:

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Intake Form