IDENTIFYING INFORMATION:
Client Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relationship to Client:
Is the Client under 18 Years of Age?
No
Yes
Relationship to Client:
Parent
Guardian
Parent/Guardian Full Name:
First Name
Last Name
Parent/Guardian Phone Number:
Please enter a valid phone number.
Client Information:
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Social Security Number:
Gender:
Date of Birth:
*
-
Month
-
Day
Year
Date
Marital Status:
Ethnicity:
Hispanic?
Please Select
Yes
No
Employed?
Please Select
Yes
No
Veteran?
Please Select
Yes
No
Legal Violation? (Past 30 Days)
*
Please Select
Yes
No
(Past 30 Days)
Reason and Type of Services:
Presenting Problem/Reason for Services:
*
Services Requested:
*
Therapy
Medication Management
Other
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TREATMENT INFORMATION
Currently Involved in Another Program or Seeing a Therapist?
*
Please Select
Yes
No
If Yes, Please Explain:
Have you previously received services at Sante?
Please Select
Yes
No
If Yes, What and When?
Primary Care Physician Name:
Primary Care Contact Number:
Currently Taking Any Medications?
*
Please Select
Yes
No
If Yes, Please List:
Hospitalization Within the Last Year?
Please Select
Yes
No
If Yes, Where, When and for What Reason?
Name of Pharmacy
Address of Pharmacy
Pharmacy Office Number
Please enter a valid phone number.
Pharmacy Fax Number
Please enter a valid phone number.
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Referral Source Information
Name of Individual Completing Form:
Agency?
EveryMind
YMCA
Basics
At Your Best
Other
Agency Phone Number
Please enter a valid phone number.
Relationship to Client:
*
Has the client been informed of referral to services?
*
Yes
No
Insurance Information:
Currently we accept Maryland Medicare and Medicaid.
Insurance Provider 1:
*
Insurance ID Number:
*
Effective Date
-
Month
-
Day
Year
Date
Insurance Provider 2:
Insurance ID Number:
Effective Date
-
Month
-
Day
Year
Date
Attach Supporting Documents Here:
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