Psychiatric Adult Intake/Screen  
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Client Name *
Does the client have a different legal name? If so, please put it below
*
Date of Birth *
MM
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DD
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Sex *
Gender Identity
Pronouns
Street Address Line 1 *
Street Address Line 2
City *
State *
Zip Code *
Email Address *
Phone Number *
Is it okay to leave a message? *
Are you a previous client? *
Who were you referred by? *
What is your availability for an appointment? *
Is the above availability flexible? *
I do not have insurance with BCN or BCBS. I would like information regarding sliding scale payment options. In order to qualify for these options, I will need to submit tax returns, pay stubs or other approved proof of income
*
Primary Insurance Information
Insurance Company *
Subscriber ID/Contract Number *
Group Number *
Employer *
Policy Holder *
Policy Holder DOB *
MM
/
DD
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YYYY
Policy Holder Relationship to Client *
Secondary Insurance Information
If no secondary insurance information, you may skip this section
Secondary Insurance Company
Secondary  Subscriber ID/Contract Number
Secondary Group Number
Secondary Insurance Employer
Secondary Insurance Policy Holder
Secondary Insurance Policy Holder DOB
MM
/
DD
/
YYYY
Secondary Insurance Policy Holder Relationship to Client
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