Get View And Print The Intake Form - Mazzitti And Sullivan

This guide provides clear instructions on how to effectively fill out the View And Print The Intake Form - Mazzitti And Sullivan online. Completing this form accurately is crucial for ensuring appropriate support and services.

Follow the steps to successfully complete your intake form.

1. Press the ‘Get Form’ button to access this document and open it for editing.
2. Begin by filling in the counselor information at the top of the form. Ensure to provide the counselor's name in the designated space.
3. In the primary diagnosis code and diagnosis code sections, accurately input the relevant codes that pertain to the client's mental health evaluation.
4. Enter the office information as required and note if the evaluation is for office use only.
5. Complete the date section with today’s date.
6. Fill out the client information section clearly. Print the client’s last name, first name, and middle initial in the specified fields. Include their street address, city, state, zip code, and email address.
7. Provide appropriate telephone numbers, including home, work, and cell, and specify the marital status and race.
8. Include the client’s name of employer, social security number, date of birth, age, and sex (select either male or female).
9. For emergency contact information, enter the contact person’s name, their relationship to the client, and their phone number.
10. If applicable, fill in the parent email contact field, especially for adolescent clients.
11. Proceed to the insurance information section. Fill out details about the guarantor and their relationship to the client.
12. Enter primary insurance company information, including the insurance phone number, subscriber name, and their relationship to the client.
13. Provide details about the subscriber's employer and primary care physician, including the subscriber's address if different from the client's address.
14. Fill in the policy ID number and group number, along with the subscriber’s date of birth.
15. If there is a secondary insurance, input the necessary details just like the primary insurance section.
16. Complete the referral information if applicable, including who referred the client and their contact details.
17. In the presenting problem area, describe the issue that brought the client for evaluation.
18. If relevant, provide the probation officer or attorney’s name and phone number.
19. Once all sections are filled, you can save changes, download, print, or share the completed form as needed.

Complete your intake form online now to ensure prompt service.