Intake Form
* Please complete and submit the information below and we will contact you and connect you with one of our therapists.
Sign in to Google to save your progress. Learn more
Office Location *
Are you available to meet with a therapist during the day (ie: 9am-3pm)? *
Client's Last Name *
Client's First Name *
Insurance Subscriber's Full Name *
Medicare Beneficiary ID (If Medicare is your primary insurance)
Client's Date of Birth *
Phone Number *
Email Address *
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) *
Referred By *
Therapist requested - please keep in mind that this does not guarantee that this therapist is accepting new clients.
Insurance *
Member ID *
Reason for Seeking Counseling Services *
Are you still interested in services if telehealth (video/phone) sessions are the only option at this time? *
Clear form
Never submit passwords through Google Forms.
This form was created inside of Main Street Counseling. Report Abuse