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Intake Form

Current Date:

Client Name:

Date of Birth:

Address:

City:

State:

Zip Code:

Phone:

Email:

Birth Sex

Male

Female

Other

Gender Identity:

Employment status:

Employee

Unemployed

Disability

Worker's Comp

Student?

Yes

No

Marital Status

Single

Married

Divorced/ Separated

Other

Adult

If you are an ADULT, please enter an Emergency Contact or indicate “DECLINED”:

Contact Name / DECLINED

Relation to you?

Contact #?

Do you authorize us to communicate with this person about your mental health treatment with us?

Yes

No

Child

If the client is a child:

Are parents divorced?

Yes

No

If so, do both parents have guardianship?

Yes

No

Who has legal guardianship & can make medical/mental health decisions on behalf of minor child?

PARENT 1:

PARENT 1:

Parent/Guardian 1 Name:

Parent/Guardian 1 Date of Birth:

Parent/Guardian 1 Address:

Parent/Guardian 1 Cell:

Parent/Guardian 1 Email Address:

Parent 2:

PARENT 2:

Parent/Guardian 2 Name:

Parent/Guardian 2 Date of Birth:

Parent/Guardian 2 Address:

Parent/Guardian 2 Cell:

Parent/Guardian 2 Email Address:

Primary Insurance

Primary Insurance:

Insurance Company:

Member ID#:

Group#:

Policy Holder Name:

Policy Holder Date of Birth:

Policy Holder Address:

Policy Holder Contact #:

Employer:

Provider/ Mental Health Phone # (on the back of the card):

Secondary Insurance

Secondary Insurance (if applicable):

Insurance Company:

Member ID#:

Group#:

Policy Holder Name:

Policy Holder Date of Birth:

Insurance Policy Holder Address:

Insurance Policy Holder Contact #:

Employer:

Provider/ Mental Health Phone # (on the back of the card):

Referred by:

REASON for seeking support:

Free Text

Specific Availability (indicate all possible options)

Monday:

Tuesday

Wednesday

Thursday

Friday

Saturday

PREFER IN PERSON OR VIRTUAL SESSIONS?

IN PERSON

VIRTUAL

Either/Or

PREFERRED LOCATION?

MIDDLEBURY

SHELTON

Either/Or

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Information

Middlebury Location
984 Southford Road
Middlebury, CT 06762
Phone: (203) 758-2400
Fax: (203) 758-2415

Shelton Location
1000 Bridgeport Avenue
Suite 202
Shelton, CT 06484
Phone: (203) 712-9998
Fax: (203) 242-1165

Email: Intake@behavioralhealthctr.com

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