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Chronic Illness (e.g., Diabetes, Autoimmune Disorders)

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Physical & Cognitive Conditions
Chronic Illness (e.g., Diabetes, Autoimmune Disorders)

Emotional support for individuals managing chronic conditions.

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Intake Form

Step 1 of 3 - Patient Details

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Are you currently experiencing thoughts of suicide?

Yes

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.

Please select a staff member you'd like to meet with.

Patient Details

Patient First Name(Required)

Patient Last Name(Required)

Are You a:(Required)

Minor

Adult

Home Phone

Work Phone

Mobile Phone

OK to Leave a Message?

Yes

No

Text

Call Only

Patient Speaks

English

Spanish

Patient Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Referred By

Have You Been Court Ordered to Therapy??(Required)

Yes

No

Please Upload the Court Order

Drop files here or

Accepted file types: pdf, jpg, png, doc, docx, webp, gif, Max. file size: 256 MB.

* Multiple files accepted

Name of Parent or Legal Guardian(Required)

First Last

Is There a Custody Agreement?(Required)

Yes

No

Please Upload the Custody Agreement

Drop files here or

Accepted file types: pdf, jpg, png, doc, docx, webp, gif, Max. file size: 256 MB.

* Multiple files accepted

Are Restrictions Specified for Either Parent in the Agreement?(Required)

Yes

No

Explain Restrictions(Required)

Are custody Issues present?(Required)

Yes

No

Briefly Explain Issues(Required)

Insurance Info

Do you have Insurance?

Yes

No

Name of Insured(Required)

Social Security #(Required)

ID Number(Required)

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State issued(Required)

Upload a photo of your ID (optional)

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

Name of Insurance(Required)

Insurance Co. Phone(Required)

Upload photo of insurance card front(Required)

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

Upload photo of insurance card back(Required)

This information is encrypted and protected via SSL (Secure Sockets Layer) a security protocol that creates an encrypted link between a web server and a web browser.

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

Are You In Network?(Required)

Yes

No

Not Sure

Have You Been Seen Yet?

Yes

No

Benefits 1 of 2

Is Provider In Network?

yes

No

Type of Service Requested

Individual

Group

Couples

Family

Adolescent

CASOMB

Type of Appointment Preferred

Select Your Desired Location(Required)

Effective Date

MM slash DD slash YYYY

Additional Notes

Example – Do Mental Health Benefits carve out?

Claims Mailing Address

Street Address Address Line 2 City State ZIP Code

Patient Signature(Required)

Parent or Legal Guardian Signature(Required)

Date

MM slash DD slash YYYY

Submit Your Resume

Upload your resume with cover letter stating areas of interest. (population and geographic locations)

First Name(Required)

Last Name(Required)

Preferred method of contact(Required)

Phone

Email

Either is fine

Phone(Required)

Email(Required)

Attach your cover letter stating your areas of interest(Required)

Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.

Attach your Resume(Required)

Accepted file types: pdf, jpg, doc, docx, Max. file size: 256 MB.