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Get Borough Intake Form
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How to fill out the Borough Intake Form online
Filling out the Borough Intake Form online is an important step in initiating your treatment. This guide provides clear, step-by-step instructions to ensure that you can complete the form accurately and efficiently in a user-friendly manner.
Follow the steps to fill out the Borough Intake Form.
- Press the 'Get Form' button to access the Borough Intake Form and open it in your online editor.
- Fill in the patient or insured details at the top of the form. This includes last name, first name, middle initial, date of birth, age, and sex. Ensure that you provide accurate and complete information.
- Provide your address, including street, city, state, and zip code. Include contact details like home phone, work phone, and cell phone numbers.
- Enter your social security number and driver's license number, as well as your marital status and information about any former or present relationships.
- List your children, siblings, and parents along with their names and ages in the designated sections.
- Complete the employer and occupation section, including the employer's address.
- If the guarantor or insured is different from above, fill in their details similarly in the respective section.
- Provide your primary insurance information, including the name of the insurance company, address, ID number, and group number.
- Detail your presenting problems, including any past or present substance use and dependency issues.
- Note any past or present medical care in the corresponding section, along with major problems and current medications.
- Provide information about any past psychotherapy or mental health hospitalizations, including presenting problems and outcomes.
- Fill out the family history section regarding chemical dependency, mental illness, violence, or suicide.
- Review the authorization statement and provide your printed name and signature at the bottom of the form.
- Once you have completed all sections, you can save your changes, download, print, or share the form as needed.
Complete the Borough Intake Form online today to take the first step towards your mental health journey.
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Typically, the client fills out the Borough Intake Form to provide their relevant details. This includes personal information, legal concerns, and any specific needs they may have. However, in some cases, legal representatives or assistants may also help clients complete the form. This collaborative approach ensures that you receive accurate and complete information.
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