Walpole Behavioral Healthcare LLC. 10 Common St. #64 Walpole, MA 02081Phone (508) 6686053Fax (508) 4227297Initial Intake Form Todays Date: Patient Name: LastPatient Date of Birth:FirstMiddle InitialPatient.
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How to use or fill out the MA Walpole Behavioral Healthcare Initial Intake Form online
Filling out the MA Walpole Behavioral Healthcare Initial Intake Form online is an important step in accessing mental health services. This guide provides clear, step-by-step instructions to help you navigate the form, ensuring that all necessary information is accurately submitted.
Follow the steps to complete the MA Walpole Behavioral Healthcare Initial Intake Form.
- Click the ‘Get Form’ button to obtain the document and open it in your preferred online editor.
- Begin with the 'Today’s Date' field, entering the current date to indicate when the form is being filled out.
- In the 'Patient Name' section, provide the last name followed by the first name and middle initial of the patient.
- Fill out the 'Patient Date of Birth' to ensure accurate identification of the patient.
- Next, indicate the 'Patient Age' to provide additional identification details.
- Complete the address fields with the patient's home address, city, state, and zip code, ensuring precision for contact and service purposes.
- Provide the home phone and cell phone numbers, with an indication of whether the cell phone belongs to the patient or a parent.
- Fill in the patient's email address for future communications regarding appointments and services.
- Identify the emergency contact by filling out their name and phone number for any urgent situations.
- List the name and phone number of the primary care provider, including their address if available.
- Detail any current medications the patient is taking, ensuring to list them clearly.
- Provide the name of the patient’s insurance company along with the insurance card number and copay amount required for mental health services.
- Include the subscriber's name, date of birth, relation to the patient, and address if different from the patient's address.
- If applicable, provide employer details for the subscriber and any necessary authorization numbers related to insurance.
- Complete the authorization fields by marking yes or no regarding the therapist's ability to contact the primary care physician and any necessary assignments of insurance benefits.
- Finally, ensure the signature of the patient or legal guardian is present along with the date to validate the form.
- After completing the form, proceed to save your changes, download a copy for your records, print the form, or share it as needed.
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