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Anela Richie

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Intake Form

Step 1 of 3 - Patient Details

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Are you currently experiencing thoughts of suicide?

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No

If you’re feeling overwhelmed or struggling with thoughts of suicide, please know that you are not alone. There are people who care about you and want to help. You can reach out to the Suicide & Crisis Lifeline by calling 988 or visiting 988lifeline.org for immediate support. If you are in an emergency, please call 911 or go to the nearest emergency room. Your life is important, and reaching out for help is a strong and courageous step.

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Patient Details

Patient First Name(Required)

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Are You a:(Required)

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Home Phone

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Text

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Patient Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Referred By

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First Last

Insurance Info

Do you have Insurance?

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Name of Insured(Required)

Social Security #(Required)

ID Number(Required)

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State issued(Required)

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Name of Insurance(Required)

Insurance Co. Phone(Required)

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Upload photo of insurance card back(Required)

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Accepted file types: jpg, jpeg, gif, png, tif, tiff, pdf, Max. file size: 256 MB.

Are You In Network?(Required)

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Not Sure

Have You Been Seen Yet?

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Benefits 1 of 2

Is Provider In Network?

yes

No

Type of Service Requested

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CASOMB

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Date

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