Client Information

Marital Status

Employment Status

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

 If the client is a CHILD:  

PARENT/GUARDIAN 1

PARENT/GUARDIAN 2

Insurance

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

Insurance Card

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

Secondary Insurance (Husky secondary or MPB Supplemental Policies only)

Employee Assistance Program (EAP)

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

Referral Source

Referral Name

Name of referral source, or N/A:

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.

Psychiatric Medications

If you are currently prescribed any psychiatric medications, please list them here, or N/A:

Prescriber Name

Name of prescriber, or N/A:

Location preference

Session preference