Get Behavioral Intake Form

Filling out the Behavioral Intake Form online is a crucial step in receiving appropriate care and support. This guide provides a clear and comprehensive process to help users complete the form effectively, ensuring that all necessary information is submitted accurately and promptly.

Follow the steps to successfully complete the Behavioral Intake Form online.

1. Press the ‘Get Form’ button to access the Behavioral Intake Form and open it in your preferred editor.
2. Begin by entering today’s date in the designated field.
3. Fill in your last name, ensuring it is your legal name, and mark accordingly.
4. Provide your first and middle names as required.
5. If your legal name differs from the name provided, indicate your legal name in the specified section.
6. Complete your marital status by circling the appropriate option: single, married, or other.
7. Enter your birth date along with your street address, city, state, and ZIP code.
8. Fill in your occupation and employer’s information.
9. Add your cell phone number; this field is mandatory. Also, provide your work phone number, if applicable.
10. Indicate how you were referred to the provider by checking the appropriate box and providing any necessary details.
11. Provide your email address and any alternative email address you utilize.
12. Identify the person responsible for the billing, including their birth date and contact information.
13. Complete the insurance section by marking whether you are covered by insurance and listing your primary insurance provider.
14. If applicable, provide the name of any secondary insurance.
15. Complete the emergency contact section with the name and contact number of your emergency contact.
16. If you have any previous diagnoses, please list them in the designated area.
17. Fill in any additional information, such as authorization numbers or insured names, as applicable.
18. Review all filled sections carefully to ensure accuracy before proceeding.
19. After completing the form, you have options to save your changes, download, print, or share the form.

Complete your Behavioral Intake Form online today to ensure a smooth process for your care.