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Client Intake Form
Hello, I am calling from Sol Counseling to get some additional information from you before your appointment. Do you have 5-10 minutes to speak with me?
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* Indicates required question
Client’s Name:
*
Your answer
DOB:
*
MM
/
DD
/
YYYY
Client’s address:
*
Your answer
Client’s phone:
*
Your answer
Client’s email:
*
Your answer
Insurance Name:
*
Your answer
Member ID:
*
Your answer
Group ID: (N/A if not applicable)
Your answer
Primary Card Member’s name: (N/A if not applicable)
Your answer
Primary Card Member’s DOB: (N/A if not applicable)
MM
/
DD
/
YYYY
Once we have verified your benefits we will let you know what your financial responsibility will be. --------------------------------------
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