Confidential Intake Form for Village Counseling Services
Last name: *
First name: *
If you are not the client, but referring a client to us, please leave your name, address, phone and email address. *
Please fill out the rest of this form as if you were the client.
Date of birth: *
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DD
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Social security number: *
Phone number where you can be reached between the hours of 9 am and 1 pm M-F: *
Additional phone number:
Email address: *
Home address: *
Who referred you, or where did you find out about VCS? *
(If referred, please include name, address, email and phone number of referrer)
Have you been a client of VCS's in the past? *
If known, please indicate the type of treatment you are seeking.
Are you currently on any medications for your mental health? *
Who prescribes your current mental health medication?
Please provide the name telephone number of the doctor.
If you are seeking medication management, please give us the name, address and telephone number of your pharmacy.
Do you prefer a female or male therapist?
Clear selection
Please list your availability (for instance, "during the day," or "evening only, " or "any day but Wednesday".
Will you be using an Employee Assistance Program (EAP) Benefit from your Employer?
If so, please provide the EAP Name, Contact person and contact phone number.
What is the name of your primary insurance company? *
(For example, Blue Cross, or Medicare)
What is the insurance type?
(For example, POS, PPO, HMO, etc.)
Name of the subscriber (if not yourself):
Social security number of subscriber (if not yourself):
Subscriber's date of birth (if not yourself):
MM
/
DD
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YYYY
Relationship of subscriber to the client: *
Insurance ID number: *
Insurance group number (If your insurance card does not have a group number, please enter N/A): *
Provider phone number, or phone for mental health or behavioral health benefits: *
Do you have a secondary insurance? *
If you do, please fill out the Secondary Health Insurance questions that follow. If not, please click "Submit" and we will contact you with appointment times. Thank you!
Secondary health insurance company name:
What is the secondary insurance type?
(For instance, POS, PPO, HMO, etc.)
Name of the secondary insurance subscriber (if not yourself):
Subscriber relationship (secondary insurance):
Clear selection
Subscriber's date of birth for secondary (if not yourself):
MM
/
DD
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YYYY
Secondary insurance ID number:
Secondary insurance group number:
Secondary insurance subscriber is employed by:
Subscriber address, if different from above (secondary insurance):
Secondary provider phone number, or phone for mental health or behavioral health benefits:
Submit
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