Employee Portal - Hawaii Behavioral Health

Serving The Hawaiian Islands

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Client Intake Information Sheet

Name

Date of Birth

Address

Parent Name

Parent Phone

Parent Email

Policy Holder

Date of Birth

Employer

Primary Insurance Carrier

Subscriber/Membership#

Group#

Type of Insurance

Quest HMO PPO

Insurance Eligibility

Yes No

Co-Payment

Qualifying Diagnosis received?

Yes No

Time when Client is available for services?

When would you like services to start?

Comments?

Does the Client currently receive HBH Services and/or works with an HBH provider?

Provider Name

Type of Service