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Intake Form

Current Date:

Client Name:

Date of Birth:

Street Address:

City:

State:

Zip Code:

Phone:

Email:

Birth Sex:

Male

Female

Other

Gender Identity:

Employment status:

Full-time employed

Part-time employed

Self-employed

Contract, per diem

Full-time student

Part-time student

On active military duty

Retired

Leave of absence

Temporarily unemployed

Unemployed

Something else

Marital Status:

Unmarried

Married

Domestic partner

Divorced

Widowed

Legally Separated

Something else

Choose not to disclose

Adult

If you are an ADULT, please enter an Emergency Contact or indicate “DECLINED”:

Contact Name / DECLINED

Relation to you:

Contact #:

Do you authorize us to communicate with this person in the event of an emergency only? Be advised that a formal release of information is needed to allow any additional access to your PHI.

Yes

No

Child

If the client is a child:

Are parents divorced?

Yes

No

If so, who has legal guardianship & can make medical/mental health decisions on behalf of minor child?

Who has residential custody?

Are both parents aware that you are seeking mental health treatment for this child?

Yes

No

If no, please explain:

PARENT 1:

PARENT 1

Parent/Guardian 1 Name:

Parent/Guardian 1 Date of Birth:

Parent/Guardian 1 Address:

Parent/Guardian 1 Cell:

Parent/Guardian 1 Email Address:

Parent 2:

PARENT 2

Parent/Guardian 2 Name:

Parent/Guardian 2 Date of Birth:

Parent/Guardian 2 Address:

Parent/Guardian 2 Cell:

Parent/Guardian 2 Email Address:

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Insurance

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Please input your insurance details fully and accurately!

Please note that our office cannot guarantee acceptance of all insurance plans. Upon receiving your completed intake form, our admin team will verify your insurance details and inform you of coverage eligibility!

Primary Insurance

Primary Insurance

Insurance Company:

Member ID#:

Group#:

Policy Holder Name:

Policy Holder Date of Birth:

Policy Holder Address:

Policy Holder Contact #:

Employer:

Mental Health Phone # (provider # if no MH # available):

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Insurance Card

Please upload clear photos of the front and back of your insurance card!

Front:

Back:

Secondary Insurance

Secondary Insurance (Husky secondary or MPB Supplemental Policies only)

Insurance Company:

Member ID#:

Group#:

Policy Holder Name:

Policy Holder Date of Birth:

Insurance Policy Holder Address:

Insurance Policy Holder Contact #:

Employer:

Mental Health Phone # (provider # if no MH # available):

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Employee Assistance Program (EAP)

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If you have EAP sessions provided to you by your employer, please complete this section:

Employer Name:

EAP Company:

Authorization #:

# of sessions authorized:

Effective Date Range:

Is this authorization already associated with a BHC provider? If yes, please indicate the provider here:

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Referrals

Referred by:

External source

Internal BHC source

Following my current provider

N/A

Referral Name:

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Reason for seeking support

Please be detailed in your reason for seeking support, so we can connect you with the right provider! "Medication" or "therapy" is not enough information for us to evaluate.

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Availability (indicate specific time slots)

Monday:

Tuesday:

Wednesday:

Thursday:

Friday:

Saturday:

Prefer in-person or virtual (telehealth) sessions?

In-person

Virtual (telehealth)

Either/or

Preferred location

Middlebury

Shelton

Either office

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Information

Middlebury Location
984 Southford Road
Middlebury, CT 06762
Phone: (203) 758-2400
Fax: (203) 758-2415

Shelton Location
1000 Bridgeport Avenue
Suite 202
Shelton, CT 06484
Phone: (203) 712-9998
Fax: (203) 242-1165

Email: Intake@behavioralhealthctr.com

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