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Intake Form
* Please complete and submit the information below and we will contact you and connect you with one of our therapists.
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Office Location
*
Allentown
Point Pleasant
Pennington
Hamilton
Moorestown
Other:
Are you available to meet with a therapist during the day (ie: 9am-3pm)?
*
yes
no
Client's Last Name
*
Your answer
Client's First Name
*
Your answer
Insurance Subscriber's Full Name
*
Your answer
Medicare Beneficiary ID (If Medicare is your primary insurance)
Your answer
Client's Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Email Address
*
Your answer
If the client is a minor and the child's parents are divorced with joint-custody, please list additional contact information below (phone & email of 2nd parent) so both parents can complete initial intake forms. (Please put N/A if not applicable)
*
Your answer
Referred By
*
Your answer
Therapist requested - please keep in mind that this does not guarantee that this therapist is accepting new clients.
Your answer
Insurance
*
Horizon BCBS
Aetna
Other:
Member ID
*
Your answer
Reason for Seeking Counseling Services
*
Your answer
Are you still interested in services if telehealth (video/phone) sessions are the only option at this time?
*
yes
no
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