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 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.

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

Secondary Insurance (Husky secondary or MPB Supplemental Policies only)

Please upload clear photos of the front and back of your secondary insurance card, if applicable. 

Employee Assistance Program [EAP]

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

Please note, BHC considers Employee Assistance Program [EAP] services on a case-by-case basis and does not automatically accept all EAP plans. After submission, the Administrative team will review the details to evaluate if your EAP can be used.

Referral Source (if applicable)

Referral Name

Name of referral source, or none:

Reason for seeking support

Please be specific about why you are seeking support, so we understand your needs and do our best to connect you with the right provider. General responses such as “therapy” or “medication” do not provide enough information for us to assess your needs and may delay the intake process!

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

Please know that the BHC does not provide emergency crisis services. If you're experiencing a mental health emergency, please utilize the following resources: 

• Life-threatening Emergency: Call 911 or go to the nearest ER
• Mental Health or Crisis Support: Call or text 988
• Local Resources & Mobile Crisis: Dial 211