Patient Intake Form
Alta Vista Integrated Life Services
7282 Stinson Ave, Suite B
Gig Harbor, WA 98335
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First/Last Name: *
Preferred Name: *
Mailing/Billing Address: *
Primary Phone: *
Secondary Phone:
Email: *
Ok to leave voicemails?
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Send emails?
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Send texts?
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Insurance Carrier: *
Subscriber: *
Group #: *
ID#: *
Phone: *
Emergency Contact (Name, Relation, Contact): *
DOB: *
MM
/
DD
/
YYYY
SSN# *
Gender Identity: *
Gender Identity (please specify):
Sexual Orientation: *
Sexual Orientation (please describe):
Ethnicity: *
Primary Language: *
Marital Status: *
Employment: *
Employer/School: *
How did you hear about us? *
What type of service are you seeking?
Yes
No
Mental Health Therapy
ABA/Behavioral Therapy
Respite Care
Parent Coaching
Educational Support
Substance Abuse Treatment
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