New Patient Intake Form

Patient Intake Form (#3)

First Name

Last Name

Date of Birth

Patient Gender

Phone no.

Address

Address Line 1

City

State

Zip Code

Country

Primary Insurance

Primary Insurance ID

Secondary Insurance

Yes

Secondary Insurance ID

Name of Company (If alternate mental health services provider stated on card)

CoPay

Yes

Primary Care Physician

Referred By

Why are you seeking help?

Past inpatient hospitalizations in the last 6 months-1 yr (Diagnosis &treatments).

Past outpatient services and Providers 6 months-1yr (Diagnosis, Treatment)

Current Psychotropic Medications

Substance Use/Abuse issue

Current Controlled Substance use

Welcome to our practice! Please feel at home. At Assured Hope Community Health, we listen, care, and are dedicated to assisting you in meeting your psychological health needs.

Massachusetts law about mental health issues

SAMHSA

Hiring LMHC and LCSW contact, [email protected] for more details