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)

Referral Source

Referral Name

Name of referral source, or N/A

Therapy Involvement

At BHC, we encourage clients receiving medication management to engage in ongoing therapy, as medication and therapy are often most effective when used together.

If you already have a therapist, please share their name, practice, and contact information:

If you do not currently have a therapist, we would be happy to connect you with one of our BHC clinicians prior to starting medication management. Please share any specific preferences you may have for a therapist, including gender or age:

Current Medications

Please list medication name and dosage. If you are not currently taking any psychiatric medications, please enter N/A.

Medical History

Please list any significant diagnoses we should be aware of. 

Substance Use

Do you use alcohol, cannabis, or any other substances? If yes, please provide details (including details of any prescribed medical marijuana card):

Pharmacy 

Please provide the name and location of your preferred pharmacy. 

Primary Care Physician/Pediatrician

Please provide the name of your primary care physician or pediatrician. 

Date of your most recent visit:

Date of most recent blood work:

Date of most recent EKG, or N/A:

Hospitalizations/Safety History

Have you ever experienced a mental health crisis that led to hospitalization or a visit to the emergency room?