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Client Intake Information Sheet

Client Information

Name

Date of Birth

Address

Parent Name

Parent Phone

Parent Email

Insurance Policy Holder Information

Policy Holder

Date of Birth

Employer

Primary Insurance Carrier

Subscriber/Membership#

Group#

Type of Insurance

Quest HMO PPO

Insurance Eligibility

Yes No

Co-Payment

Treatment / Services

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